Exhibits
Click to highlight the findings that would indicate the client is progressing as expected.
The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
The client reports he was able to sleep through the night
The left arm is warm to touch. The client's left shoulder and collarbone are symmetric
The client reports mild nausea and has no desire to eat breakfast
The Correct Answer is ["A","B"]
The client reports he was able to sleep through the night: This indicates pain management may be effective, allowing the client to rest, which is a positive sign of progress.
The left arm is warm to touch: This suggests good circulation in the injured limb, which is crucial for healing.
The client’s left shoulder and collarbone are symmetric: Symmetry suggests that the alignment of the shoulder and collarbone is stable, which indicates no further dislocation or misalignment post-injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Taking out dentures is generally not done, as it can be considered disrespectful and is not a standard procedure before family viewing.
B. Gently closing the eyes is a common practice to present the body respectfully to the family.
C. Removing resuscitation equipment from the room is essential to create a peaceful environment for the family.
D. Applying a body shroud is appropriate to cover the body respectfully before family viewing.
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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