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Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Assess the client's pain

Increase the propofol infusion

Notify the social worker the client is awake.

Have the client sign consent forms for procedures already performed

Consider extubating the client

Determine the client's decision-making ability

Decrease the noise and light stimuli in the room as much as possible

Explain all procedures

Answer and Explanation

Correct Answer : A,F,G,H

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Neglect is the most appropriate option because the client’s inability to access the restroom independently and lack of adequate personal care, as indicated by poor hygiene, tangled hair, matted nails, and untreated wounds, are signs of neglect. Additionally, the client is being kept bedridden against her will, which points to a lack of adequate care and respect for her autonomy, further supporting neglect.

Adult Protective Services (APS) is the proper agency to contact when there are concerns about elder neglect or abuse. APS is responsible for investigating suspected abuse, neglect, and exploitation of vulnerable adults.

A. Technical assistance to produce a video on breast self-examination. B. Morbidity data for breast cancer in women of all races. C. A listing of African-American women who live in the community. D. Participation of community leaders in planning the program.

Correct Answer is D

Explanation

A. A video on breast self-examination is useful but does not ensure engagement.
B. Morbidity data for all races does not focus on African-American women specifically.
C. A listing of community members may not ensure meaningful participation.
D. Involving community leaders fosters trust and cultural relevance, increasing program effectiveness.

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Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits New data is reviewed. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. This client is exhibiting signs of dropdown. The nurse is a mandated reporter and therefore must report the elder mistreatment todropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct Answer is D

Explanation

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

Patient Data Exhibits Select the 4 assessment findings that require immediate follow up.

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is (are) the legal implication(s) of the nurse's signature on the client's surgical consent form? Select all that apply.

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.