A patient has been hospitalized after her house was destroyed in a hurricane.
She has spent two weeks in the intensive care unit and has now been transferred to the surgical floor for continued respiratory monitoring and completion of IV antibiotic therapy.
The patient reports a pain level of 2 on a scale of 0 to 10. She requests sleeping medication, explaining that she is haunted by distressing thoughts and memories of the house collapsing, which prevent her from sleeping.
She says, “I used to be so happy before all of this happened.
Now I can’t seem to get out of this funk I am in.”. She would also prefer a quieter area of the unit as she is currently near the nurses’ station and is disturbed by the noise.
After listening to the patient’s symptoms, the nurse suspects that she likely has:

Phobia.

Acute stress disorder related to traumatic stress exposure.

Hallucinations.

Separation anxiety.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.

Choice B rationale

The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.

Choice C rationale

Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.

Choice D rationale

Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.

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Correct Answer is D

Explanation

Choice D rationale

In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.

A. Monitor an IV infusion rate on an established schedule. B. Titrate oxygen to the prescribed parameters. C. Insert a urinary catheter for an uncomplicated patient. D. Procure platelet products from the blood bank.

Correct Answer is C

Explanation

Choice A rationale

Monitoring an IV infusion rate on an established schedule requires assessment skills and clinical judgement to identify and respond to potential complications. This task should be performed by a registered nurse.

Choice B rationale

Titration of oxygen to prescribed parameters is a complex task that requires advanced assessment skills and a deep understanding of the patient’s condition and response to treatment. This task should not be delegated to unlicensed assistive personnel (UAP).

Choice C rationale

Inserting a urinary catheter for an uncomplicated patient is a task that can be safely delegated to UAP who have been trained and demonstrated competence in this skill. It is a routine procedure and does not require advanced assessment or decision-making skills.

Choice D rationale

Procuring platelet products from the blood bank is a task that involves handling and transporting biological materials, which requires specific knowledge and skills. This task should not be delegated to UAP.

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Naxlex Comprehensive Predictor Exams

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

After receiving a change of shift report for patients on a medical-surgical unit, which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

A 33-year-old female client, who denies smoking, drinking, or using any illicit drugs, exercises 2 to 3 times per week and has an office job.She weighs 68 kg and is 156 cm tall.Which of the following actions would be effective in maintaining her energy balance?

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.