Exhibits

The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.

Complete the following sentence by choosing from the lists of options.

Based on the information collected, the client is likely experiencing
related to

Answer and Explanation

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

Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure

Rationale

The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.

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Correct Answer is C

Explanation

A. While it's important to monitor for complications, this is not a typical initial instruction for a soft tissue injury.
B. Early range of motion exercises are generally not recommended for acute soft tissue injuries, as they can increase swelling and pain.
C. This is the correct instruction. Applying ice to the injured area helps reduce swelling and pain. It should be applied intermittently to prevent tissue damage from excessive cold.
D. Heat is typically used in the later stages of healing to promote blood flow and relaxation, but continuous heat application can be harmful in the acute phase.

A. Assist the client with learning how to set priorities and pace activities. B. Instruct the client about the importance of maintaining bedrest. C. Consult the discharge planner about transferring the client to an assisted living center. D. Offer assurance that the fatigue inducing stage of the disease does not last.

Correct Answer is A

Explanation

A. RA often causes joint pain and stiffness, which can make it challenging to complete daily activities. Teaching the client how to set priorities and pace their activities helps them balance exertion with rest, thus reducing fatigue and improving overall function. This approach supports effective management of their condition by preventing overexertion and allowing time for recovery.
B. While rest is important for managing fatigue, strict bedrest is generally not recommended for RA patients. Prolonged bedrest can lead to muscle weakness, joint stiffness, and decreased mobility. Active management through appropriate rest and activity is usually more beneficial than complete bedrest.
C. Transferring to an assisted living center may be appropriate for some clients, but this intervention is not necessarily related to managing fatigue due to rheumatoid arthritis in the current context. This
decision would typically depend on the overall level of care needed and the client’s living situation.
D. While providing reassurance is part of supportive care, it’s important to address the specific needs and management strategies for fatigue. Simply offering assurance without practical interventions may not effectively address the client’s current symptoms or help them manage their condition in the long
term.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

Correct Answer is C

Explanation

The nurse establishes a nursing problem of "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?

Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?