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

Exhibits

Drag words from the choices below to fill in each blank in the follow sentence.

The client is at risk for developing

and .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Rationale for Correct Choices:

  • Decreased cardiac output: The client is post–myocardial infarction and experiences chest pain with minimal exertion, tachycardia (HR 112/min), and signs of anxiety and fear. These findings suggest that myocardial function may be compromised. Decreased cardiac output is a significant risk in post-MI clients due to potential for reinfarction, ischemia, or left ventricular dysfunction.
  • Respiratory failure: The client has COPD, an elevated respiratory rate (32/min), and oxygen saturation of 87% on room air, which indicates significant hypoxemia. The productive cough, fatigue, and shortness of breath increase the risk for decompensation into respiratory failure without prompt oxygen therapy and pulmonary support.

Rationale for Incorrect Choices:

  • Pancytopenia: This condition involves a reduction in red blood cells, white blood cells, and platelets. There is no evidence of bone marrow suppression, recent chemotherapy, or hematologic disorder in this client’s history.
  • Neurogenic shock: Neurogenic shock results from spinal cord injury or disruption of sympathetic nervous system control. The client has no evidence of trauma or spinal pathology, and the elevated heart rate contradicts the expected bradycardia of neurogenic shock.
  • Hepatic encephalopathy: This is caused by liver dysfunction, typically in clients with advanced liver disease. There are no signs of altered mental status, liver disease, or elevated ammonia levels in this case.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Set up the sterile field 5 cm (2 in) below waist level: Sterile fields must be at or above waist level to maintain sterility. Anything below the waist is considered contaminated because it is out of the nurse’s visual field and control.

B. Place the cap from the solution sterile side up on a clean surface: The inside of the cap must face up to avoid contamination. Placing it on a clean surface with the sterile side up preserves sterility for recapping the solution if needed.

C. Open the outermost flap of the sterile kit toward the body: The first flap should be opened away from the body to prevent reaching over the sterile field, which increases the risk of contamination.

D. Place the sterile dressing within 1.25 cm (0.5 in) of the ledge of the sterile field: Items must be placed at least 2.5 cm (1 in) from the edge of the sterile field. The outer 1 inch is considered non-sterile and any item placed within this margin is no longer sterile.

Correct Answer is B

Explanation

Rationale:

A. Refer to the hallucinations as if they are real: Acknowledging hallucinations as real reinforces the client’s delusions and may worsen their psychosis. The nurse should avoid validating the hallucinations while still responding with empathy and support.

B. Ask the client directly what they are hearing: Directly asking helps assess the content, intensity, and risk associated with the hallucinations. It also opens therapeutic communication and enables the nurse to determine if the client poses a danger to themselves or others.

C. Avoid eye contact with the client: Avoiding eye contact can hinder trust and communication. Establishing a calm and respectful presence, including appropriate eye contact, supports rapport and promotes client engagement.

D. Encourage the client to lie down in a quiet room: While reducing external stimuli can help manage hallucinations, isolating the client without first assessing the hallucination’s content may not be appropriate. This action also doesn’t address the client's perception or emotional needs directly

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