An older client's spouse reports to the nurse that there has been a behavior change in the client for the past several days. The client was recently seen by the healthcare provider at the clinic and was treated for seasonal allergies and insomnia. Which action is most important for the nurse to implement?

Encourage the client to engage in social activities.

Review medications for drug and food interactions.

Appraise light sensitivity, tiredness, and dizzy spells.

Observe carefully for extrapyramidal symptoms (EPS).

Answer and Explanation

The Correct Answer is B

A. Encouraging social activities may benefit the client in the long term but does not directly address the immediate concern of the reported behavior change.

B. Reviewing medications for drug and food interactions is crucial, especially since the behavior change could be related to new medications or combinations that the client was prescribed. This assessment can help identify any adverse effects or interactions affecting the client's mental status.

C. Appraising for light sensitivity, tiredness, and dizzy spells is important but does not directly address the most pressing concern of behavioral changes which could be medication-related.

D. Observing for extrapyramidal symptoms (EPS) is important if the client is on antipsychotic medication, but the more immediate step is to ensure that medications are not contributing to the behavior change.

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Correct Answer is D

Explanation

A. The degree of skin elasticity is not the most immediate concern in this context.

B. Length of capillary refill is important but does not provide specific information regarding the client's cardiac rhythm or possible arrhythmias.

C. The volume of pedal pulses can provide information about peripheral circulation but is less critical than assessing the heart's rhythm.

D. Assessing the rhythm of the apical pulse is crucial because the client’s symptoms suggest possible cardiac arrhythmia, which needs immediate attention.

A. Clenched fists. B. Restlessness. C. Peripheral pallor of the skin. D. Increased respiratory rate. E. Increased temperature. F. Increased pulse rate.

Correct Answer is ["A","B","D","F"]

Explanation

A. Clenched fists can indicate discomfort or pain in infants, suggesting the need for pain management.

B. Restlessness is often a sign of pain or discomfort in infants and requires assessment for pain relief.

C. Peripheral pallor can indicate other issues such as shock or anemia but is not a direct indicator of pain.

D. An increased respiratory rate can be a response to pain or distress, indicating the child may need pain medication.

E. An increased temperature could indicate infection or inflammation, but it is not a direct indicator of pain requiring medication.

F. An increased pulse rate may indicate pain or anxiety and should be considered in the context of the child's overall assessment.

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Naxlex Comprehensive Predictor Exams

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?