A nurse is caring for a client on an acute mental health unit.
Complete the following sentence by using the list of options.
The nurse should delegate the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Daily weights: This task can be delegated to ensure consistent monitoring of the client's weight, which is crucial for assessing nutritional status and progress.
Observing meals: The nurse should focus on observing meals to ensure the client is eating properly and not engaging in behaviors such as pocketing food or spitting it out, which are common in clients with eating disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Kawasaki Disease
Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms.
Actions to Take:
Plan to administer high dose of aspirin:
High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms.
Assess for neurological changes:
Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease.
Parameters to Monitor:
Daily weights:
Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction.
Reports of chest pain or pressure:
Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.
Correct Answer is C
Explanation
A. Return in two weeks for a follow-up MRI: MRI is generally contraindicated for clients with ICDs unless the device is MRI-compatible.
B. Expect to have a rapid pulse rate for the first few weeks: ICDs do not cause a sustained rapid pulse rate.
C. Wear loose-fitting clothing: Loose clothing prevents irritation and promotes healing of the surgical site, reducing the risk of infection.
D. Resume tub baths and swimming after 24 hr: Clients should avoid soaking the surgical site until fully healed.
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