Exhibits

Review H and P, nurse's note, and laboratory results.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition
Polycythemia

Tetralogy of Fallot, a congenital heart condition, often leads to decreased oxygenation, which triggers the body to produce more red blood cells to compensate, resulting in polycythemia.

Actions the nurse should take:

Take the child’s vital signs: Monitoring vital signs is essential to assess the child's overall stability and detect any signs of distress or hypoxia.

Ask the child’s parents about the frequency of tet spells: Tet spells (hypercyanotic episodes) are common in children with Tetralogy of Fallot, and understanding their frequency helps assess the child's current condition and plan interventions.

Parameters to monitor:

Oxygen saturation: Monitoring oxygen levels is crucial to determine how well the child is oxygenating and to detect any hypoxia or cyanosis.

Weight: Monitoring weight is important in this child, who is in the lower percentiles for growth, as poor weight gain may indicate the need for nutritional or medical intervention.

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

Explanation

A. Consciousness raising - This term generally refers to efforts aimed at increasing awareness and understanding of issues, often in the context of social change. While it might be beneficial in some therapeutic contexts, it is not a specific treatment approach that would directly address the client's symptoms of anxiety and distress.

B. Cognitive behavioral therapy (CBT) - CBT is an effective treatment for anxiety, depression, and post-traumatic stress symptoms, which the client may be experiencing after her traumatic event. This therapy focuses on identifying and changing negative thought patterns and behaviors, making it a suitable option for this client.

C. Animal therapy - Animal-assisted therapy can provide emotional support and reduce feelings of anxiety and depression. Interaction with animals has been shown to improve mood and provide comfort, making it a helpful adjunct treatment for this client.

D. Phototherapy - This treatment is typically used for seasonal affective disorder and some forms of depression. However, it may not be specifically beneficial for this client’s situation, which is more acute and related to trauma rather than seasonal mood changes.

E. Electroconvulsive therapy (ECT) - ECT is generally reserved for severe depression or treatment-resistant psychiatric disorders. It is not appropriate for the client at this time based on the current information, as her symptoms do not warrant such an intensive intervention.

F. Administration of lithium - Lithium is primarily used for mood stabilization in bipolar disorder and does not apply to the symptoms described in this case. The client’s symptoms indicate anxiety and depression rather than a mood disorder requiring lithium.

A. Limit activity for a day or two after returning home. B. Anticipate a stinging feeling during needle insertion. C. Prepare to sit forward with arms propped on a table. D. Expect a persistent cough after the procedure.

Correct Answer is D

Explanation

A. Limiting activity after the procedure is appropriate to ensure recovery and minimize complications.

B. Anticipating a stinging feeling during needle insertion is a normal expectation and indicates understanding.

C. Preparing to sit forward with arms propped is correct, as this position facilitates access for the procedure.

D. Expecting a persistent cough is incorrect; while some coughing may occur due to irritation, a persistent cough should be reported as it may indicate complications.

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Naxlex Comprehensive Predictor Exams

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

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

Explanation

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Correct Answer is D

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?

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Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

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