br>History and Physical

BP 100/60 mm Hg Pulse 52/min
Respiratory rate 20/min

Temperature 37.2" C (99.0° F)

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the

client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer furosemide.

Withhold digoxin.

Withhold spironolactone.

Administer ferrous sulfate.

Answer and Explanation

The Correct Answer is B

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

A. The client follows the nurse's simple instructions. B. The client apologizes for their aggressive behavior. C. The client requests that the restraints be removed. D. The client maintains eye contact while talking with the nurse.

Correct Answer is A

Explanation

- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?

Correct Answer is A

Explanation

A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?

Correct Answer is A

Explanation

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following Instructions should the nurse include?

A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse discovers that the wrong dosage of a medication was given to a client. When determining what action to take, the nurse should recognize that which of the following ethical principles should be applied?