After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Red blood cell count (RBC).

Core body temperature.

Swollen lymph nodes in the groin.

Location of the initial intravenous (IV) site.

White blood cell count (WBC).

Answer and Explanation

Correct Answer : B,C,E

A)   Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B)   Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C)   Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D)   Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E)   Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.

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Correct Answer is ["A","E","F"]

Explanation

A) Correct- The client's statement suggests a misconception about the progression from acute stress disorder (ASD) to post-traumatic stress disorder (PTSD). While ASD is an initial response to trauma, it doesn't necessarily indicate a high risk for developing PTSD. The nurse should provide education about the differences and the various factors that influence the development of PTSD.

B) Incorrect- This statement reflects the client's proactive approach to using holistic approaches like meditation to manage symptoms. Meditation and other relaxation techniques can be beneficial for managing stress and anxiety related to the traumatic event.

C) Incorrect- This statement reflects the client's motivation to learn how to manage their thoughts better through therapy. Therapy can be highly effective for addressing trauma-related distress and helping clients develop coping strategies.

D) Incorrect- This statement reflects the client's recognition that their response is shared by many people in similar situations. Validating the client's experience and normalizing their feelings can be therapeutic.

E) Correct- This statement reflects a common misconception and stigma associated with mental health diagnoses. The nurse should reassure the client that a diagnosis of acute stress disorderdoes not equate to being "crazy" and provide information about the nature of the disorder and available treatments.

F) Correct- The statement implies a potential pessimistic outlook on treatment. While medication might be part of the treatment plan, it's important to emphasize that treatment approaches are individualized. Encouraging an open dialogue about various treatment options, including therapy and coping strategies, is essential.

A. Disturbed Body Image. B. Interrupted Family Processes. C. Imbalanced Nutrition: less than body requirements. D. Noncompliance with treatment regimen.

Correct Answer is C

Explanation

less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications.

Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

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After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","E","F"]

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is C

Explanation

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

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