A nurse is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse understands that the patient has likely developed

and will need to be monitored for ___
.

Answer and Explanation

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

Lithium toxicity: The client's lithium level is significantly elevated at 2.5 mEq/L (normal range is 0.6 to 1.2 mEq/L), and symptoms such as blurred vision, increased urine output, and clonic jerking of the upper extremities are indicative of lithium toxicity2.
Seizure activity: Lithium toxicity can lead to neurological symptoms, including seizures, which require close monitoring

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Correct Answer is C

Explanation

A. Immobility more commonly leads to orthostatic hypotension rather than increased blood pressure.

B. Immobility typically leads to increased calcium levels due to bone demineralization.

C. A swollen area on the calf may indicate a deep vein thrombosis (DVT), a serious complication of immobility.

D. Urinary stasis and retention, rather than frequency, are common complications of immobility.

A. Encourage the family to assign specific tasks to individual family members. B. Assist the family to establish a daily routine. C. Refer the family to a grief support group. D. Determine the roles of individual family members.

Correct Answer is D

Explanation

A. Assigning tasks is important but comes after understanding family dynamics.

B. Establishing a routine is beneficial but should follow assessment.

C. Referring to a support group is valuable but not the immediate first step.

D. Determining family roles helps the nurse assess coping strategies and dynamics, which is essential before planning interventions.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed ______ and will need to be monitored for _________.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

Correct Answer is C

Explanation

A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take?

A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?

A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care?

A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse understands that the patient has likely developed

and will need to be monitored for ___
.