A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

Traumatic brain injury

Chronic pain

Sexual Dysfunction

Depression

Effective coping strategies

Risk for suicide

Answer and Explanation

Correct Answer : A,D,F

A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.

B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.

C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.

D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.

E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.

F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.

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Correct Answer is D

Explanation

A. While medication review may be necessary, the immediate concern is the client's current symptoms and potential need for urgent intervention.
B. Encouraging the client to eat more slowly does not address the urgent nature of the client's symptoms.

C. "Assessment security" is not a standard term or intervention. It does not provide specific guidance for addressing the client's symptoms.
D. Given the client's complaints of swelling and tightness, along with difficulty swallowing, further assessment is needed to determine the cause. This information should be reported to the provider promptly.

A. Diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting. B. Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizures. C. Cravings, depression, fatigue, hypersomnolence, and impaired judgment. D. Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks.

Correct Answer is A

Explanation

A) Correct. These symptoms are indicative of opioid withdrawal. Opioid withdrawal symptoms include sweating (diaphoresis), goosebumps (piloerection), tremors, irritability, insomnia, and gastrointestinal symptoms like nausea and vomiting.

B) Incorrect. These symptoms are more indicative of withdrawal from substances like alcohol or benzodiazepines, rather than opioids.

C) Incorrect. These symptoms are not specific to opioid withdrawal and may be seen in various conditions.

D) Incorrect. This cluster of symptoms is not characteristic of opioid withdrawal.

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A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?

Correct Answer is D

Explanation

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Correct Answer is A

Explanation

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