A nurse is reviewing the day 5 vital signs.
A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.
Vital signs
Movement through the stages of grief
Cognition
Participation in group therapy
Appetite
The client resolves to limit alcohol consumption
Correct Answer : A,B,D,E
Choice A Reason: Vital signs are a critical indicator of a patient’s health status. Normal ranges for vital signs in a resting adult include a body temperature of 97.8°F to 99.1°F (36.5°C to 37.3°C), blood pressure between 90/60 mmHg and 120/80 mmHg, a pulse rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 18 breaths per minute. The client’s vital signs have stabilized from the initial erratic readings to within normal ranges by hospital day 5, indicating a positive response to the treatment plan.
Choice B Reason: Movement through the stages of grief is essential for emotional recovery, especially in the context of alcohol use disorder where the grief may have triggered the relapse. The stages of grief include denial, anger, bargaining, depression, and acceptance. Progress in these stages can be a sign of emotional healing and a successful coping mechanism in the recovery process.
Choice D Reason: Participation in group therapy is a key component of substance use disorder treatment. It provides social support, reduces isolation, and helps develop effective communication and interpersonal skills3. Active participation in group therapy sessions indicates the client’s engagement with the treatment process and their commitment to recovery.
Choice E Reason: Appetite changes are common during recovery from alcohol use disorder. Initially, there may be a loss of appetite due to the effects of alcohol on the gastrointestinal system and overall health. However, as recovery progresses, appetite usually returns, and the individual may even overeat5. An improvement in appetite suggests that the client’s physical health is improving and that they are regaining a normal relationship with food.
Choice C Reason: Cognition refers to the mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging, and problem-solving. These are higher-level functions of the brain and encompass language, imagination, perception, and planning. A person’s cognitive ability can be affected by alcohol use disorder, as alcohol can impair cognitive functions and damage brain structures. However, recovery from alcohol abuse can lead to improvements in cognitive functions. Research indicates that most noticeable improvement in cognitive function begins after one year of abstinence from alcohol. Therefore, if the client shows signs of improved cognition, such as better memory, clearer thinking, or improved problem-solving, it would indicate progress in their recovery.
Choice F Reason: The client’s resolve to limit alcohol consumption is a significant indicator of their commitment to long-term recovery. Setting limits on alcohol intake is a crucial step in the process of recovery and can help prevent relapse. For men, moderate drinking is defined as up to two drinks per day and for women, up to one drink per day3. If the client expresses a desire to limit their alcohol consumption to within these guidelines, or better yet, abstains from alcohol completely, it would demonstrate a positive change in behavior and mindset towards their health and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood
Indicates potential worsening a. Giving away car b. Condition of skin on right hand
Choice A: Giving away car
This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.
Choice B: Hygiene
The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.
Choice C: Food intake
The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.
Choice D: Condition of skin on right hand
The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.
Choice E: Rapid change in mood
The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.
Correct Answer is B
Explanation
Choice A reason: Telling the client that the symptoms will improve over time without further assessment could be misleading. These symptoms could indicate lithium toxicity, which requires immediate medical attention.
Choice B reason: Lethargy, muscle weakness, and blurred vision can be signs of lithium toxicity. The nurse should recommend blood tests to check lithium levels and kidney function to rule out toxicity.
Choice C reason: Decreasing sodium intake is not recommended without a healthcare provider's advice, as sodium levels can affect lithium levels in the body. Sudden changes in sodium intake should be avoided unless directed by a healthcare provider.
Choice D reason: Continuing the medication as prescribed without addressing the symptoms could be dangerous. The symptoms reported by the client need to be evaluated to ensure they are not due to lithium toxicity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.