A nurse in a clinic is caring for an older adult client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Digoxin Toxicity: The client’s symptoms (nausea, vomiting, diarrhea, weakness), vital signs (bradycardia), and lab results (high digoxin level, low potassium and magnesium) suggest digoxin toxicity.

Cardiac Monitor: To detect any arrhythmias resulting from digoxin toxicity.

Icterus: To assess liver function, which could be impacted in severe toxicity.

Electrolytes: Imbalances in potassium and magnesium can worsen digoxin toxicity and need to be corrected.

Fever: The fever might indicate an infection or inflammatory process, which can affect treatment and recovery.

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Correct Answer is C

Explanation

A. Neurologic deficits increasing over 2 weeks are more characteristic of subdural hematomas, not epidural hematomas.
B. A change in the level of consciousness that develops over 48 hours is typical of subdural hematomas.
C. An epidural hematoma often presents with a brief period of lucidity followed by a rapid decline in consciousness due to arterial bleeding.
D. Cognitive perception that decreases over several months post-injury is not typical of epidural hematomas, which generally cause acute and rapid changes.

A. Instruct the client on the use of crutches. B. Perform neurovascular checks of the extremities. C. Medicate the client for pain. D. Direct the client to perform exercises of the ankle and toes.

Correct Answer is B

Explanation

A. Instructing the client on the use of crutches is important but not as immediately critical as monitoring for complications.

B. Performing neurovascular checks of the extremities is the most important action to detect complications such as compartment syndrome or impaired circulation.

C. Medicating the client for pain is important but secondary to immediate assessment for complications.

D. Directing the client to perform exercises of the ankle and toes is important for recovery but not as urgent as monitoring for postoperative complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Correct Answer is B

Explanation

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

A nurse is teaching an assistive personnel (AP) about the purpose of a footplate on the bed of a client whose leg is in Buck's traction. Which of the following statements indicates the AP understands the teaching?

A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings?

A nurse is reviewing the medication history of a client who has a new prescription for colchicine. Which of the following medications increases the client's risk when used in combination with colchicine for developing rhabdomyolysis?

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures?