A nurse preparing incoming storm. Which of the following clients should the nurse recommend for discharge planning?
A child who has leukemia and an absolute neutrophil count of 200/mm3 (2.500 to 8.000/mm%)
A child who has a new diagnosis of type diabetes mellitus and is receiving IV insulin
An adolescent who has cystic fibrosis and is receiving their yearly tune-up
An infant who has respiratory syncytial virus and respiratory rate of 70/min
The Correct Answer is B
A) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.
B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.
C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.
D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Patient Health Questionnaire - 9:
The Patient Health Questionnaire-9 (PHQ-9) is a screening tool used to assess the severity of depression in a client. It is not specific to detecting tardive dyskinesia, which is a movement disorder caused by long-term use of antipsychotic medications. Therefore, this tool is not appropriate for assessing tardive dyskinesia.
B) Abnormal Involuntary Movement Scale:
The Abnormal Involuntary Movement Scale (AIMS) is the correct tool to screen for tardive dyskinesia. It is specifically designed to assess involuntary movements, such as those seen in tardive dyskinesia, which is a common side effect of long-term use of antipsychotic medications. The AIMS evaluates the presence and severity of abnormal movements, making it the most appropriate tool for this purpose.
C) Mental Status Examination:
The Mental Status Examination (MSE) is a broad assessment used to evaluate a client’s cognitive and emotional functioning. It includes aspects such as appearance, behavior, mood, thoughts, and perception but does not specifically assess for movement disorders like tardive dyskinesia. While it can provide useful information about a client's mental state, it is not focused on detecting motor side effects of antipsychotic medications.
D) Brief Psychiatric Rating Scale:
The Brief Psychiatric Rating Scale (BPRS) is used to assess the severity of psychiatric symptoms, including delusions, hallucinations, and mood disturbances, primarily in individuals with schizophrenia or other psychiatric disorders. It does not specifically assess for tardive dyskinesia, so it is not the most appropriate screening tool for identifying this condition.
Correct Answer is A
Explanation
A) "The headaches should decrease as you get used to the medication.": This statement is correct. A common side effect of isosorbide dinitrate is headaches, as the medication works by dilating blood vessels, which can cause a drop in blood pressure. These headaches typically occur when the medication starts, but they often decrease over time as the body adjusts to the drug. The nurse should reassure the client that this side effect is generally temporary.
B) "You should take the medication on an empty stomach to prevent a headache.": This statement is incorrect. While taking certain medications on an empty stomach may affect their absorption, isosorbide dinitrate is typically not recommended to be taken on an empty stomach to avoid headaches. In fact, it is more common for people to take it with food if it causes gastrointestinal discomfort, but this is not directly related to preventing headaches.
C) "You can discontinue the medication until the headache goes away.": This statement is incorrect. The client should not discontinue the medication without consulting the healthcare provider. Abruptly stopping isosorbide dinitrate can lead to withdrawal symptoms and potentially worsen the client's condition. The nurse should encourage the client to talk to their provider if the headache becomes unbearable or persistent, but not to stop the medication without guidance.
D) "Swallow the tablet whole to minimize your headaches.": This statement is incorrect. Isosorbide dinitrate in chewable form is designed to be chewed, as this method of administration helps the drug be absorbed more quickly and effectively. Swallowing the tablet whole would not address the issue of headaches and could affect how the medication works.
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