A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.

Exhibits

Complete the following sentence by selecting the most appropriate actions based on the client’s current status.

The nurse should first
dropdown
then
dropdown
.

Answer and Explanation

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

The nurse should first: Response 1: Notify the primary health care provider immediately.

This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.

Then, the nurse should: Response 2: Start an IV line for potential medication administration.

Starting an IV line ensures that the client can receive any necessary medications quickly.

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Correct Answer is C

Explanation

Choice A rationale

Using a narrower cuff can result in an inaccurate blood pressure reading by providing artificially high values due to increased pressure on a smaller surface area.

Choice B rationale

Requesting a prescription for an antihypertensive medication is premature without verifying the accuracy of the initial blood pressure measurement and considering other factors that might have influenced the reading.

Choice C rationale

Measuring the client's blood pressure in the other arm can help confirm the initial reading. Differences in readings between arms can occur, and a second measurement ensures accuracy and proper assessment.

Choice D rationale

Deflating the cuff faster when repeating the blood pressure measurement can lead to inaccurate readings. The cuff should be deflated at a standard rate to ensure reliability and accuracy in the measurement. .

A. "We can discuss this when you're not feeling overwhelmed.”. B. "Have you tried taking your partner with you when you go out?" C. "Tell me more about your expectations.”. D. "I understand how you feel. I've had a relative go through the same thing.”

Correct Answer is C

Explanation

Choice A rationale

Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.

Choice B rationale

Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.

Choice C rationale

Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.

Choice D rationale

While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.

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Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.The client's BP was 126/72 mm Hg 15 min ago.The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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