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Exhibits

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0900

Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "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." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking

requests sleeping medication for the night

keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep

can't seem to get out of this funk I am in

prefer to be in a quieter area of the unit

currently by the nurses' station

pain is 2 on a 0 to 10 pain scale

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Rationale

The client is experiencing significant psychological distress characterized by intrusive thoughts and memories related to the traumatic event (house collapsing during a hurricane). These thoughts are causing her difficulty in falling asleep and impacting her emotional well-being. Her statement about feeling unable to get out of a "funk" suggests that she may be experiencing symptoms of acute stress or post-traumatic stress disorder (PTSD). It's crucial to address her psychological distress promptly to provide support and prevent exacerbation of her symptoms.

Sleep Difficulties: The client requests sleeping medication due to her difficulty in falling asleep. Sleep disturbances are common after experiencing a traumatic event and can further contribute to emotional distress and hinder recovery. It's important to assess her sleep patterns and consider appropriate interventions, such as pharmacological sleep aids under medical supervision, to help her achieve adequate restorative sleep.

Environment: The client expresses a preference for a quieter area of the unit away from constant noise (talking and alarms). Hospital environments can be noisy and disruptive, which can exacerbate anxiety and sleep difficulties. Ensuring she is in a quieter environment or making adjustments to minimize noise near her can improve her comfort and facilitate better sleep, which is essential for recovery and emotional well-being.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Rationale

A. Nausea and headache are common side effects of linezolid. While they can impact the client's comfort and adherence to treatment, they are generally not considered urgent or life-threatening unless severe or persistent.

B. Watery diarrhea is a significant concern with linezolid therapy, as it can indicate the development of Clostridium difficile infection (CDI) or other types of antibiotic-associated diarrhea. CDI is a severe condition that requires prompt treatment to prevent complications such as dehydration, colitis, and potentially life-threatening outcomes like toxic megacolon.

C. Increased fatigue can be a nonspecific symptom and may result from various factors, including the underlying illness (nosocomial pneumonia), medication side effects, or the stress of hospitalization. While it should be monitored, it is typically not an immediate concern unless accompanied by other concerning symptoms.

D. Yellow-tinged sputum can indicate the presence of infection or inflammation in the respiratory tract, which is relevant in the context of nosocomial pneumonia. It could suggest a worsening of the pneumonia or a new infection. However, it is not typically directly associated with linezolid therapy itself.

A. Select foods that are lower in caloric density B. Increase exercise intensity C. Get up and walk at least once an hour at work D. Add healthy foods to increase caloric intake E. Avoid food with high carbohydrate levels

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A. Select foods that are lower in caloric density
Effective: Choosing foods that are lower in caloric density (such as fruits, vegetables, lean proteins) can help the client feel fuller with fewer calories. This can support weight maintenance or even weight loss if that is the goal.

B. Increase exercise intensity
Effective: Increasing exercise intensity can help the client burn more calories, contributing to energy expenditure. This can assist in achieving energy balance, particularly if the client wants to maintain her current weight while consuming adequate calories.

C. Get up and walk at least once an hour at work
Effective: Incorporating regular physical activity throughout the day, such as walking breaks, helps increase energy expenditure. It also breaks up sedentary behavior, which is beneficial for overall health and can contribute to energy balance.

D. Add healthy foods to increase caloric intake
Ineffective: Adding healthy foods to increase caloric intake would likely lead to a positive energy balance (where intake exceeds expenditure), potentially causing weight gain. Since the goal is to maintain weight, increasing caloric intake, even with healthy foods, would not be effective.

E. Avoid food with high carbohydrate levels
Ineffective: Carbohydrates are an important source of energy. Avoiding foods with high carbohydrate levels could limit the client's energy intake, potentially leading to negative energy balance if not replaced adequately with other nutrients.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

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