A nurse is caring for a client in an emergency department.
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
The Correct Answer is []
Based on the provided nurses' notes, the client exhibits symptoms that may suggest a brief psychotic disorder, characterized by delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The client's history of similar episodes and family history could support this diagnosis. To assess the client's progress, the nurse should monitor the client's ability to care for themselves and assess any suicide risk due to the client's recent stressors and emotional state. Actions that could be beneficial include reducing external stimuli to prevent sensory overload and engaging with the client several times each day to establish trust, which can help alleviate anxiety and foster a therapeutic environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Excessive sweating is a common adverse effect of sertraline, and it is essential for the nurse to educate the client about this potential side effect to enhance medication adherence and manage expectations.
B. Dry cough is not typically associated with sertraline, and its inclusion in the education may confuse the client and undermine the credibility of the nurse's teaching.
C. Increased urinary frequency is not commonly reported with sertraline use; therefore, including it in the client education may lead to misinformation.
D. A metallic taste in the mouth is not a commonly reported adverse effect of sertraline and should not be included in the client education as it may cause unnecessary concern or confusion.
Correct Answer is C
Explanation
A. Circulatory overload is characterized by symptoms such as dyspnea, crackles, and increased blood pressure, rather than localized redness and warmth.
B. Extravasation refers to the leakage of IV fluid into surrounding tissue, causing swelling and pain.
C. Redness and warmth around the peripheral catheter insertion site are indicative of phlebitis, which is inflammation of the vein. It's essential to document this finding accurately to monitor for worsening or complications.
D. Infiltration occurs when IV fluid leaks into the surrounding tissue, but it typically presents with swelling, pallor, and coolness at the site rather than redness and warmth.
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