Exhibits

Select from the options to complete the sentence.

After listening to the client's symptoms, the nurse realizes that she likely has
dropdown
related to
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

After listening to the client's symptoms, the nurse realizes that she likely has acute stress disorder related to traumatic stress

Acute Stress Disorder: This diagnosis fits because the client is experiencing significant distress and anxiety related to the traumatic event (her house collapsing during a hurricane). Acute stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, and avoidance behaviors following exposure to a traumatic event. The client's symptoms of persistent thoughts about the event, difficulty sleeping due to these thoughts, and feeling unable to return to her previous emotional state ("funk") are indicative of acute stress disorder.

Traumatic Stress: This describes the source of the client's symptoms. The collapse of her house during a hurricane is a traumatic event that has triggered her acute stress disorder symptoms. Traumatic stress refers to the psychological and emotional response to a deeply distressing or disturbing event.

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Correct Answer is D

Explanation

Rationale

A. This approach might inadvertently increase feelings of isolation and worsen agitation. Older adults with dementia often benefit from social interaction and engagement. Limiting interaction could lead to increased confusion and behavioral issues.

B. Attempting to correct or argue with the client about their delusions is generally not effective and can escalate agitation. Clients with dementia may not have the cognitive ability to understand or accept reality as others perceive it. Therefore, trying to clarify or correct delusional thoughts is unlikely to be helpful and may increase distress.

C. While maintaining a consistent routine is beneficial for clients with dementia, forcibly awakening the client earlier could disrupt their natural sleep patterns and contribute to increased confusion and agitation. It's important to balance the need for routine with the client's individual sleep and rest patterns.

D. This approach focuses on redirecting the client's attention away from the distressing thoughts and behaviors. Distraction techniques involve engaging the client in activities or topics that they find enjoyable or comforting. Therapeutic communication skills include active listening, empathy, and validating the client's emotions without reinforcing delusions.

A. Leave the client's room and return later in the day. B. Refer client to the social worker for support therapy. C. Encourage client to implement relaxation techniques. D. Explain that insulin is a life-saving drug for the client.

Correct Answer is A

Explanation

Rationale

A. This allows the client time to process their emotions. A diagnosis with a chronic illness can be overwhelming.

B. Referring the client to a social worker for support therapy is a good idea for ongoing emotional support and counseling. However, at this moment, the client might need immediate assistance

C. While relaxation techniques can be helpful in managing stress and anxiety, they might not address the immediate need for insulin administration education.

D. Explaining the importance of insulin, is crucial, but it may not be effective if the client is not in a receptive state.

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Exhibits Select from the options to complete the sentence. After listening to the client's symptoms, the nurse realizes that she likely has dropdown related to dropdown

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Naxlex Comprehensive Predictor Exams

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Correct Answer is D

Explanation

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Correct Answer is A

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

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?

Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

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

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Exhibits

Select from the options to complete the sentence.

After listening to the client's symptoms, the nurse realizes that she likely has
dropdown
related to
dropdown