Exhibits

The nurse is planning care for the client.

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 []

Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.

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Correct Answer is D

Explanation

A. Asking vague or nonspecific questions can lead to unclear answers, which may hinder the assessment process. Specific and direct questions are more effective.
B. Starting with the most difficult questions may make the client uncomfortable and less willing to share information. It's better to build rapport first.
C. Sharing personal values is not appropriate as it may influence or pressure the client. The focus should be on the client’s values and experiences.
D. Beginning with questions that are less sensitive helps to build rapport and trust with the client, making them more comfortable discussing more sensitive topics later in the conversation.

A. White blood cell count. B. Serum sodium levels. C. Serum potassium levels. D. Creatinine clearance.

Correct Answer is B

Explanation

A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?

Correct Answer is D

Explanation

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

Correct Answer is B

Explanation

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?

The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?