A nurse in an emergency department is caring for a client.
Which of the following information provided by the client indicates improvement? Select all that apply.
“I have gained 1.8 kg (4 lb) recently, and my BMI is 18.9.”
“My adult child prepares two meals per day for me.”
“My clothing is always clean and appropriate for the weather.”
“I receive three baths per week from a home care aide.”
“I frequently have toothaches and haven’t had dental care in a while.”
“I make eye contact and smile while speaking.”
Correct Answer : A,B,E
The correct answer is choice a, b, e.
Choice A rationale: A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.
Choice B rationale: Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.
Choice C rationale: Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.
Choice D rationale: Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.
Choice E rationale: Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.
Choice F rationale: Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The client is observed displaying a shuffling gait while walking in the hall is the correct answer. The nurse should recognize that observing a shuffling gait in a client who is taking antipsychotic medication is an adverse effect that must be reported to the healthcare provider. A shuffling gait is a movement disorder known as parkinsonism, which can be a side effect of some antipsychotic medications, particularly first-generation or typical antipsychotics.
Parkinsonism includes symptoms similar to Parkinson's disease, such as a shuffling walk, muscle stiffness, tremors, and difficulty with balance and coordination. It can occur as a result of blocking dopamine receptors in the brain, leading to an imbalance in dopamine levels.
Choice B reason:
The client mumbling quietly while alone is not correct because in the day room may be related to the symptoms of schizophrenia, and it does not indicate an adverse effect of the antipsychotic medication.
Choice C reason:
The client feeling light-headed when standing up quickly is not correct and it may be related to postural hypotension, which can be a side effect of some antipsychotic medications. While it should be monitored and reported if persistent or severe, it is not as urgent as reporting a shuffling gait.
Choice D reason:
The client stating that being in the sun hurts their eyes does not necessarily indicate an adverse effect of the antipsychotic medication. It may be related to other factors or unrelated to the medication.
Correct Answer is C
Explanation
Answer and explanation.
The correct answer is choice C, hypertension. Hypertension is a contraindication to living kidney donation because it can increase the risk of kidney disease and cardiovascular complications in the donor. Hypertension can also affect the quality and survival of the donated kidney in the recipient.
Therefore, a potential donor with uncontrolled or poorly controlled hypertension should not undergo nephrectomy.
Choice A, osteoarthritis, is not a contraindication to living kidney donation.
Osteoarthritis is a degenerative joint disease that does not affect the kidneys or the cardiovascular system.
It may cause pain and stiffness in the joints, but it can be managed with medications and physical therapy. A potential donor with osteoarthritis can donate a kidney if they have normal kidney function and no other medical problems.
Choice B, primary glaucoma, is not a contraindication to living kidney donation.
Primary glaucoma is a condition that causes increased pressure in the eye and can lead to vision loss if untreated.
It does not affect the kidneys or the cardiovascular system. A potential donor with primary glaucoma can donate a kidney if they have normal kidney function and no other medical problems.
Choice D, amputation, is not a contraindication to living kidney donation.
Amputation is the surgical removal of a limb or part of a limb due to injury, infection, or disease.
It does not affect the kidneys or the cardiovascular system. A potential donor with amputation can donate a kidney if they have normal kidney function and no other medical problems.
Normal ranges for blood pressure are less than 120/80 mmHg for systolic and diastolic pressure, respectively.
Normal ranges for kidney function are eGFR above 60 mL/min/1.73 m2 and albuminuria below 30 mg/g.
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