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A nurse on a step-down unit is admitting a client.

Exhibits

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Nurses' Notes
Day 3, 1350:
Client transferred to step-down unit from ICU for continued care following a myocardial infarction (MI) 2 days ago. Oriented to room. Client reports a productive cough, States they are short of breathand that ambulating to the bathroom has resulted in chest pain. Reports pain as 3 on a scale of 0 to 10. Client appears anxious and reports a fear of dying.

Oriented to room.

Client reports a productive cough

States they are short of breathand that ambulating to the bathroom has resulted in chest pain.

Reports pain as 3 on a scale of 0 to 10.

Client appears anxious and reports a fear of dying.

Answer and Explanation

The Correct Answer is ["B","C","E"]

Rationale for Correct Findings:

Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.

Rationale for Incorrect Findings:

Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. "Morphine 3 mg SQ every 4 hr PRN for pain.": The abbreviation "SQ" is considered unsafe and can be misinterpreted. The Joint Commission recommends avoiding this abbreviation and writing out "subcutaneous" to ensure clarity and patient safety.

B. "Morphine 3.0 mg sub q every 4 hr PRN for pain.": Using a trailing zero (e.g., "3.0 mg") increases the risk of a dosing error if the decimal point is missed. Standard documentation practices recommend omitting trailing zeros for whole numbers.

C. "Morphine 3 mg subcutaneous every 4 hr PRN for pain.": This entry uses the full name "subcutaneous," avoids unsafe abbreviations, and omits the trailing zero, adhering to safe and standardized medication documentation guidelines.

D. "Morphine 3 mg SC q4hr PRN for pain.": Both "SC" and "q4hr" are discouraged abbreviations. "SC" can be confused with "SL" (sublingual), and "q" abbreviations can be misread. Writing terms in full reduces the risk of misinterpretation.

A. Relationship status B. Concerns about Coworkers C. Client statement D. Skin alterations E. Behavior pattern

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Rationale:

Relationship status: BPD is marked by instability in relationships, often due to intense fear of abandonment or difficulty managing emotional attachments. Sudden breakups or conflict with close partners are common, especially during emotional crises.
Concerns about coworkers: Individuals with PPD often misinterpret benign actions of others as malicious or threatening. Persistent beliefs that others are conspiring against them—despite little or no evidence—are core features of the disorder.
Client statement: Impulsivity is a diagnostic criterion for BPD. Risky behaviors like sudden, financially irresponsible purchases are driven by difficulty regulating emotion and can reflect an effort to escape negative feelings.
Skin alterations: Recurrent self-harm (e.g., superficial cutting) is a hallmark of BPD, typically used to cope with overwhelming emotional distress, feelings of emptiness, or perceived rejection or abandonment.
Behavior pattern: Blunted affect and lack of improvement may reflect emotional withdrawal seen in both BPD and PPD. In BPD, emotional dysregulation underlies these symptoms; in PPD, chronic mistrust can lead to guarded, affectively flat behavior and resistance to help.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

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