A nurse in a provider's office is caring for a 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 []

Rationale:

The client exhibits hallmark symptoms of Systemic Lupus Erythematosus (SLE), including a butterfly rash on the cheeks, alopecia, joint tenderness, and elevated ANA and ESR levels. These findings, combined with anemia and thrombocytopenia, are consistent with SLE, an autoimmune disorder characterized by systemic inflammation and tissue damage.

Multiple sclerosis is primarily a neurological condition and does not align with the client’s dermatological and hematological findings. Celiac disease is associated with gastrointestinal symptoms and gluten sensitivity, which the client denies. Type 1 diabetes mellitus involves hyperglycemia and insulin deficiency, which are not relevant to the presented symptoms.

Helping the client identify aggravating factors (e.g., sunlight exposure, stress) is crucial for managing SLE. Recommending low-impact exercises can help maintain joint mobility and reduce inflammation.

Monitoring adherence to corticosteroid therapy is essential since these medications are often used to control inflammation in SLE. Assessing for depression related to body image is important due to the physical manifestations of SLE, such as alopecia and hyperpigmentation, which may affect the client’s mental health.

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Correct Answer is D

Explanation

A. Neurogenic bladder refers to bladder dysfunction due to nerve damage and is not related to the positioning of the urinary catheter or IV tubing.

B. Skin breakdown could be a concern with immobility or moisture around the catheter site, but the primary risk from the kinked tubing and improper catheter bag positioning is infection, not skin breakdown.

C. Phlebitis is inflammation of the vein, typically caused by an IV site issue, but this is not related to the urinary catheter or tubing.

D. Infection is the primary concern when the urinary catheter is not properly positioned. A kinked IV tubing can cause pressure and backflow, and if the catheter bag is not positioned below the bladder, it can increase the risk of urinary tract infections (UTIs). Proper positioning and drainage of the catheter are essential to prevent infection.

A. Metoprolol 5 mg every 2 to 3 min up to three doses B. Oxygen at 2 L/min via nasal cannula C. Draw electrolytes along with Hgb and Hct D. Morphine 6 mg IV bolus every 3 hr as needed for pain E. Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses F. Obtain daily weight G. Atropine 0.5 mg IV bolus every 5 min up to 2 mg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}

Explanation

Rationale:

Metoprolol: Metoprolol is commonly prescribed in acute myocardial infarction (MI) to reduce heart rate and decrease myocardial oxygen demand. It is indicated for this client who is presenting with symptoms of a potential MI, including tachycardia and chest pain.
Oxygen at 2 L/min via nasal cannula: Oxygen therapy is indicated to increase oxygen supply to the myocardium and help relieve symptoms of hypoxia, especially in a client with chest pain and shortness of breath.
Draw electrolytes along with Hgb and Hct: Electrolytes should be checked to monitor for imbalances that can occur during a myocardial infarction or as a result of treatment (e.g., potassium levels). Hgb and Hct levels are also relevant for assessing overall oxygen-carrying capacity and fluid status.
Morphine 6 mg IV bolus every 3 hr as needed for pain: Morphine is a common analgesic used in MI management to relieve pain and reduce anxiety, which can decrease the workload on the heart.
Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses: Nitroglycerin is used to relieve chest pain by dilating coronary arteries and improving blood flow to the heart. This prescription is appropriate for the client, assuming there are no contraindications (e.g., hypotension).
Obtain daily weight: While monitoring weight is important in managing heart failure, it is not immediately essential for this acute MI situation. Therefore, this is nonessential at this time.
Atropine 0.5 mg IV bolus every 5 min up to 2 mg: Atropine is used to treat bradycardia. However, the client is presenting with tachycardia, not bradycardia, so atropine would be contraindicated in this situation.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is D

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}

Explanation

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