Exhibits
Click to highlight the aspects of the assessment that require urgent attention.
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 and alarms constantly.
horrible thoughts and memories about the house collapsing
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."
prefer to be in a quieter area of the unit
she is currently by the nurses' station and hears talking and alarms constantly
The Correct Answer is ["A","B","C","D"]
Horrible Thoughts and Memories: The client expresses having "horrible thoughts and memories" about the house collapsing, which indicates the possibility of acute stress reactions or post-traumatic stress disorder (PTSD). This mental health concern needs immediate attention to ensure the client's psychological well-being.
Difficulty Falling Asleep: The client's difficulty falling asleep due to intrusive thoughts is concerning. Sleep is crucial for recovery, and ongoing sleep disturbances can exacerbate mental health issues and impede healing. Addressing her need for sleep medications or alternative interventions should be prioritized.
Emotional State: The client 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," indicating possible depression or an adjustment disorder. This emotional state warrants evaluation and support from a mental health professional.
Request for Quieter Area: The client requests a quieter area of the unit due to the noise from the nurses' station. While this may not be as urgent as the mental health concerns, accommodating her request can significantly improve her comfort and ability to rest
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. Cottage cheese can be high in sodium, which is not recommended for clients with hypertension.
B. Canned soup often contains high sodium levels, making it unsuitable for a low-sodium diet.
C. Pickled olives are typically high in sodium, which can worsen hypertension.
D. Fresh or frozen vegetables without sauce are low in sodium and high in nutrients, making them an excellent choice for a hypertensive diet.
E. Fruits without sauce are naturally low in sodium and provide essential vitamins and minerals, making them a healthy option.
Correct Answer is A
Explanation
A. Ensuring the client takes a diuretic every morning is the first intervention because it addresses fluid overload, which is indicated by the significant weight gain and elevated blood pressure. Diuretics help reduce excess fluid and alleviate symptoms of SIADH.
B. Measuring ankle circumference is useful for assessing edema but is not the immediate priority compared to addressing fluid overload through diuretics.
C. Monitoring daily sodium intake is important for managing SIADH, but the priority is to manage the fluid overload first.
D. Obtaining serum creatinine levels daily is part of monitoring kidney function, but it is not the immediate concern compared to managing fluid balance in this context.
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