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: Pancreatitis
Rationale:
The client's presentation with severe upper left quadrant abdominal pain, nausea, febrile status, tachypnea, and increased amylase and lipase levels suggests pancreatitis. Pancreatitis commonly presents with abdominal pain, nausea, and vomiting (though vomiting is not reported here), and elevated pancreatic enzymes (amylase and lipase). The elevated glucose level (200 mg/dL) may also point to pancreatitis since the pancreas plays a role in glucose metabolism.
Actions to Take:
Administer opioids for pain:
Rationale: Pain management is crucial in pancreatitis. Administering opioids like morphine or hydromorphone can help manage the severe pain, improving comfort and reducing distress.
Maintain separate equipment for the client:
Rationale: In cases of pancreatitis, particularly if caused by an infectious etiology, it is essential to avoid cross-contamination. Separate equipment reduces the risk of spreading infections if relevant.
Parameters to Monitor:
Dyspnea:
Rationale: The patient is tachypneic, and it's important to monitor for any progression of respiratory issues. Dyspnea could indicate worsening respiratory status or complications such as pleural effusion.
Hypotension:
Rationale: Hypotension can be a sign of shock, a potential complication of pancreatitis due to fluid loss, or systemic inflammatory response. It is important to monitor for signs of hypotension to ensure adequate perfusion and prevent shock.
Correct Answer is A
Explanation
A. Ensuring the client has an alert system addresses immediate safety and the risk of falls, which is a priority for a client with mobility impairments.
B. Support groups are beneficial for emotional support but are secondary to physical safety.
C. Transportation resources are important but do not address the urgent need for fall prevention.
D. Home physical therapy is important for recovery but does not immediately ensure the client's safety.
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