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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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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

A. Pickled olives. B. Fruits without sauce. C. Fresh or frozen vegetables without sauce. D. Cottage cheese. E. Canned soup.

Correct Answer is ["B","C"]

Explanation

Rationale

A. High in sodium due to pickling, which is not suitable for someone with hypertension.

B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.

C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.

D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.

E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is B

Explanation

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Correct Answer is ["B","C"]

Explanation

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

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