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Exhibits

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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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Correct Answer is C

Explanation

Rationale

A. This client may require complex care related to liver disease and alcoholism, likely exceeding the scope of practice for a PN.

B. While this client requires specialized wound care and diabetes management, the tasks involved may be appropriate for a PN under RN supervision.

C. This client's care typically involves routine postoperative monitoring and interventions that are suitable for a PN under RN supervision.

D. This client requires specialized ostomy care and postoperative monitoring, which can generally be managed by a PN under RN supervision.

A. Keep the nails trimmed short. B. Bathe the child daily with bath oil. C. Apply baby lotion to the skin twice daily. D. Allow the child to wear only 100% cotton clothing.

Correct Answer is A

Explanation

Rationale

A. Children with eczema often scratch their itchy skin, which can lead to skin breakdown, bleeding, and secondary infections. Short nails minimize the trauma inflicted on the skin during scratching and help prevent complications.

B. Bathing helps to hydrate the skin and remove allergens, bacteria, and other irritants that can exacerbate eczema. Bathing daily with bath oil helps to moisturize the skin and prevent dryness. Bath oils or emollients should be used instead of harsh soaps, which can strip the skin of natural oils and worsen dryness. However, it's essential to ensure the water is not too hot and to limit bath time to avoid drying out the skin.

C. Moisturizing the skin is a cornerstone of eczema management. Applying a moisturizer, such as baby lotion or emollient cream, helps to hydrate the skin, reduce dryness, and protect the skin barrier. Moisturizers should ideally be applied at least twice daily, especially after bathing or showering when the skin is damp to lock in moisture. Choosing a moisturizer that is fragrance-free and hypoallergenic is beneficial to avoid further irritation.

D. Cotton clothing is recommended for children with eczema because it is breathable and less likely to irritate sensitive skin compared to synthetic fabrics. Cotton allows better air circulation around the skin, which can help prevent overheating and sweating, both of which can exacerbate eczema symptoms. Avoiding wool and synthetic fabrics that can cause friction and irritation is important.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

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