A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy

A client who has cervical cancer and an internal radioactive implant

A client who had a radical mastectomy 36 hr ago and has a surgical drain

A client who had a lobectomy and has a chest tube drainage system

Answer and Explanation

The Correct Answer is C

The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.

The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.

The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.

The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.

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Correct Answer is A

Explanation

The normal range for potassium levels is generally between 3.5 to 5.0 mEq/L. A potassium level of 3.5 mEq/L falls within the lower end of the normal range, suggesting that the client's potassium levels are relatively stable. This finding alone does not indicate the overall effectiveness of the behavioral plan.

The normal range for sodium levels is typically between 135 to 145 mEq/L. A sodium level of 130 mEq/L falls below the normal range and indicates hyponatremia (low sodium levels). Hyponatremia can be a cause for concern, and it suggests that the behavioral management plan may need further attention or adjustments.

The normal range for hemoglobin (Hgb) levels varies depending on factors such as age and gender. However, in general, a Hgb level of 10 g/dL falls below the normal range and indicates anemia. Anemia is a common complication in individuals with anorexia nervosa and can result from inadequate nutrient intake. This finding suggests that the behavioral plan may need further evaluation and adjustment to address the client's nutritional needs.

Body Mass Index (BMI) is a measure that relates weight and height. A BMI of 14.5 indicates severe underweight and is well below the normal range. This finding suggests that the client's nutritional status is still significantly compromised, and the behavioral management plan may require further attention to support weight restoration and overall recovery.

A. Administer an anti-anxiety medication. B. Explore behaviors that have helped to reduce the client's anxiety in the past. C. Minimize environmental stimuli in the client's surroundings. D. Explain to the client that anxiety causes physical manifestations

Correct Answer is C

Explanation

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

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A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

Correct Answer is A

Explanation

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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