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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 D

Explanation

Rationale

A. Continuing with the tracheostomy care procedure while a code blue is ongoing for another client is not appropriate. A code blue takes precedence as it indicates a life-threatening emergency requiring immediate response.

B. Closing the room door is not a priority action during a code blue. The immediate focus should be on responding to the emergency and providing assistance as needed.

C. If additional help is needed to assist with the tracheostomy care procedure, calling for an assistant could be appropriate under normal circumstances. However, during a code blue, the primary responsibility is to respond to the emergency immediately.

D. A code blue indicates a cardiac or respiratory arrest, which requires immediate intervention. As a nurse, responding to the code blue involves providing assistance with cardiopulmonary resuscitation (CPR), fetching emergency equipment, and supporting the healthcare team in resuscitative efforts.

A. Baked potato with skin, raw carrots. B. Pancakes, whole-grain cereals. C. Roasted turkey, canned vegetables. D. Roast pork, fresh strawberries.

Correct Answer is C

Explanation

Rationale

A. Both baked potato with skin and raw carrots are high-fiber foods. The skin of the potato and raw carrots contain significant amounts of fiber, which can aggravate symptoms of ulcerative colitis.

B. Whole-grain cereals are high in fiber, which is not suitable for a low-fiber diet recommended for ulcerative colitis.

C. Roasted turkey is a lean protein source and generally suitable for a low-fiber diet. Canned vegetables can vary in fiber content; however, they are typically lower in fiber compared to fresh vegetables. The nurse should verify the specific type of canned vegetables to ensure they are low in fiber.

D. Fresh strawberries are high in fiber and should be avoided on a low-fiber diet.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is D

Explanation

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

Correct Answer is C

Explanation

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