A nurse is assisting with the care of a client.

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 []

This question focuses on identifying major depressive disorder in a client presenting with alcohol use, flat affect, poor hygiene, social withdrawal, job loss, and verbalization of hopelessness (“life is not worth living”). Depression is a mood disorder characterized by persistent low mood, loss of interest, impaired functioning, and increased risk of self-harm. In acute care settings, priority nursing actions include ensuring safety, especially monitoring for suicidal ideation, and providing supportive therapeutic communication. Sleep disturbances are also a common physiologic manifestation of depressive disorders.

Rationale for correct choices:

• Major depressive disorder: The client demonstrates classic features of major depressive disorder, including flat affect, poor hygiene, social withdrawal, and expressions of hopelessness. The statement about life not being worth living strongly suggests depressive cognition and possible suicidal risk. Functional decline after job loss further supports a depressive episode. Alcohol use may exacerbate depressive symptoms but does not explain the overall presentation alone.

• Remain in the room with the client: Remaining with the client is a safety intervention that helps reduce the risk of self-harm, especially given the verbalization of hopelessness. Continuous presence allows the nurse to observe for escalating suicidal ideation or impulsive behavior. It also provides emotional support and reassurance in a controlled environment. This is a priority for clients at risk of self-directed harm.

• Assist the client to identify stressors: Helping the client identify stressors promotes therapeutic communication and encourages expression of emotions. The client has significant psychosocial stressors such as job loss and possible alcohol misuse. Exploring these stressors helps guide coping strategies and future interventions. This is an appropriate early step in psychiatric nursing care.

• Suicidal ideation: Suicidal ideation is a critical parameter to monitor in clients with major depressive disorder. The client has already expressed passive death wishes (“life is not worth living”), which places them at high risk. Ongoing assessment helps determine escalation toward active suicidal intent. Monitoring is essential for immediate safety planning and intervention.

• Sleep patterns: Sleep disturbance is a common physiological symptom of depression, often presenting as insomnia or hypersomnia. Monitoring sleep patterns helps evaluate severity and response to treatment. Depression-related fatigue and low energy are closely linked to disrupted sleep cycles. Tracking sleep also assists in measuring overall improvement.

Rationale for incorrect choices:

• Schizophrenia: Schizophrenia typically presents with positive symptoms such as hallucinations, delusions, disorganized speech, and impaired reality testing. This client does not demonstrate perceptual disturbances or thought disorganization. Instead, the presentation is centered on depressed mood, hopelessness, and functional decline following a psychosocial stressor. The absence of psychotic features makes schizophrenia an unlikely diagnosis.

• Dementia: Dementia is a progressive neurocognitive disorder characterized by gradual memory loss, impaired judgment, language difficulties, and decline in executive function over time. This client’s cognitive function is not described as impaired, and there is no evidence of progressive memory loss or disorientation. The onset of symptoms is linked to psychosocial stress and alcohol use rather than neurodegeneration.

• Dependent personality disorder: Dependent personality disorder involves pervasive excessive need to be taken care of, leading to submissive and clinging behavior. Clients typically struggle with decision-making and fear separation, often relying heavily on others for reassurance. This client instead demonstrates withdrawal, flat affect, and hopelessness rather than dependency-seeking behavior.

• Encourage client to eat slowly: This intervention is related to clients with swallowing difficulties or gastrointestinal issues, not depression. The client’s primary concern is mood disturbance and safety rather than nutritional intake behavior. There is no evidence of dysphagia or eating disorder requiring this instruction. Therefore, it is not relevant to the current condition.

• Determine client’s level of orientation: Orientation assessment is more relevant in conditions such as delirium or dementia rather than major depressive disorder. This client is alert and able to communicate logically, even though affect is flat. Cognitive disorientation is not a primary feature here. Therefore, this is not a priority intervention.

• Speak with the client using simple words: While clear communication is always beneficial, using overly simplified language is not necessary for a cognitively intact client with depression. The client does not show evidence of intellectual impairment or confusion. Therapeutic communication, not simplification, is the priority. Therefore, this intervention is not essential.

• Wandering at night: Wandering is primarily associated with dementia-related cognitive decline, not depression. There is no indication of cognitive impairment or disorientation in this client. The client’s symptoms are mood-related rather than neurodegenerative. Therefore, this parameter is not relevant.

• Panic attacks: Panic attacks are characteristic of anxiety disorders rather than major depressive disorder. The client’s presentation is consistent with persistent low mood and hopelessness rather than acute episodic fear. There are no reported symptoms of panic such as palpitations or sudden intense fear.

• Hallucinations: Hallucinations are associated with psychotic disorders or severe mood disorders with psychotic features, which are not evidenced in this case. The client demonstrates depressive symptoms without perceptual disturbances. There are no reports of sensory misinterpretations or delusions. Therefore, hallucinations are not a relevant monitoring parameter.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Prioritizing interventions for an older adult ICU client experiencing acute delirium secondary to suspected postoperative infection (likely sepsis from an infected hip surgical site) is an essential component of care. The client shows classic delirium features including disorientation, hallucinations, agitation, and fluctuating cognition. Management requires addressing the underlying cause (infection) while simultaneously reducing environmental stimuli to prevent worsening confusion. Priority care follows both medical stabilization and supportive environmental control.

Rationale for correct choices:

• Contact the provider for an antibiotic prescription: The client’s fever, hypotension, elevated WBC count, and infected surgical wound with purulent drainage strongly indicate a postoperative wound infection progressing toward sepsis. Infection is a major reversible cause of delirium, so treating the underlying cause is the highest priority. Antibiotic therapy is essential to control infection and prevent further systemic deterioration. Without treating the infection, delirium will persist or worsen.

• Dim the lights: Delirious clients benefit from a calm, low-stimulation environment to reduce sensory overload and agitation. Bright lighting, noise, and excessive stimulation can worsen confusion and hallucinations. Dim lighting helps promote rest and orientation while reducing anxiety and behavioral disturbances. This intervention supports safety and cognitive stabilization.

Rationale for incorrect choices:

• Ask the client’s partner to leave the room: Family presence is often protective in delirium because familiar individuals provide orientation, reassurance, and emotional stability. Removing the partner could worsen agitation, fear, and disorientation. The client already shows severe confusion and hallucinations, making familiar support beneficial.

• Increase the volume on the television: Increasing sensory stimulation is contraindicated in delirium because it can worsen confusion and agitation. Loud or excessive auditory input increases cognitive overload and may intensify hallucinations. The client already demonstrates severe perceptual disturbances, so additional stimulation is harmful. This action would worsen rather than improve the condition.

• Place the client in 4-point restraints: Restraints are a last-resort intervention and are not appropriate for initial management of delirium. They can increase agitation, risk of injury, and worsen confusion, especially in older adults. Restraints do not address the underlying cause of delirium or promote reorientation. Less restrictive interventions such as environmental modification should always be attempted first.

• Assist with elimination: Assisting with elimination is a basic nursing need, but it is not a priority intervention for acute delirium management in this scenario. The client is experiencing severe confusion, hallucinations, and agitation secondary to likely sepsis, which requires stabilization of infection and environmental control first. While toileting needs should always be addressed, it does not directly improve the acute neurocognitive disturbance or safety risks.

A. Add a humidifier to the oxygen device. B. Examine the client's nail beds. C. Place the client in the supine position. D. Encourage client to perform deep breathing exercises. E. Prepare to administer oxygen via Venturi face mask

Correct Answer is ["A","B","D"]

Explanation

Post-anesthesia care unit (PACU) management focuses on maintaining airway patency, adequate ventilation, and oxygenation following sedation or anesthesia. Clients are at increased risk for hypoventilation, airway obstruction, and atelectasis due to residual anesthetic effects. Oxygen therapy must be titrated based on oxygen saturation trends and clinical status. Nurses continuously assess respiratory function and escalate oxygen delivery methods when needed to maintain adequate oxygenation.

Rationale:
A. Adding a humidifier to the oxygen device is appropriate because higher oxygen flow rates can dry mucous membranes, especially when oxygen is increased to 4–5 L/min. Humidification helps maintain airway moisture, improves secretion clearance, and enhances patient comfort during oxygen therapy. This is particularly important in postoperative clients receiving supplemental oxygen.

B. Examining the client’s nail beds is appropriate because peripheral perfusion and oxygenation status can be indirectly assessed through nail bed color and capillary refill. Although pulse oximetry is primary, physical assessment provides additional information about oxygen delivery to tissues. Pale or cyanotic nail beds may indicate inadequate oxygenation requiring further intervention.

C. Placing the client in the supine position is not appropriate because it can decrease lung expansion and increase the risk of airway obstruction, especially in a sedated postoperative client. The semi-Fowler’s position is preferred as it promotes lung expansion and improves oxygenation. Supine positioning may worsen hypoventilation in PACU patients.

D. Encouraging deep breathing exercises is appropriate because it promotes alveolar expansion and helps prevent atelectasis following sedation or anesthesia. Deep breathing improves oxygen exchange and supports removal of anesthetic gases. This intervention is essential in preventing postoperative pulmonary complications.

E. Preparing to administer oxygen via Venturi face mask is inappropriate because a Venturi mask is typically used when a very precise, high concentration of oxygen is required, often for clients with COPD. For a client in the PACU experiencing mild postoperative desaturation, a nasal cannula or a simple face mask is usually sufficient unless the saturation continues to drop despite being at the maximum flow rate for those devices.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing.

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the nurses notes admission assessment, vital sign 5. and laboratory data. Complete the following sentence by using the list of options. The nurse should first plan to dropdownand thendropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is assisting with the care of a client in a PACU Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?

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A nurse is discussing hand hygiene with an assistive personnel (AP). Which of the following statements by the AP indicates an understanding of the teaching?

A nurse is collecting data from a client who is 8 hr postoperative following an appendectomy. Which of the following manifestations is the best indication that the client needs a PRN analgesic?