A nurse is assisting in the care of a client.

Nurses' Notes Day 1 0800:

Client is alert and oriented

Breath sounds are clear and present throughout. Denies tobacco use.

Client lives in a 20-year-old, one-story house with their partner. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 2,000 mL of

fluid/day.

Day 1,1000:

2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf.

Calf circumference:

Left: 40 cm (15.8 in)

Right: 38.1 cm (15 in)

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing:

lead poisoning

pneumonia

atherosclerosis

constipation

pulmonary embolism

Answer and Explanation

The Correct Answer is B

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Orthostatic hypotension is characterized by a drop in blood pressure upon standing,
which can lead to dizziness or lightheadedness and increase the risk of falls, especially in older adults.
B. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg
within 3 minutes of standing up.

C. Orthostatic hypotension does not directly increase the risk of a pulmonary embolism.

A pulmonary embolism is a separate medical condition involving a blockage in one of the pulmonary arteries in the lungs.
D. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure, not diastolic blood pressure.

A. Tell the family that someone should plan to stay with the client. B. Place the client in a quiet room at the end of the hallway. C. Keep the client's personal items within reach. D. Provide bright lighting in the client's room at night.

Correct Answer is C

Explanation

C. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.

Incorrect options:

A. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.

B. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.

D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?

A nurse knows that the major effect of immobility on the gastrointestinal system is the lack of natural movement of the intestines, which is known as

A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

While supervising a student who is manually transferring a patient from bed to chair, a nurse intervenes when the student transfers the patient while

A patient begins to fall during ambulation. The nurse would

A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?