Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

"I can learn to manage my thoughts better through therapy."

"This diagnosis means that I am crazy."

"Many people have the same response to a stressful situation as I am having right now."

"I can use holistic approaches like meditation to help my symptoms."

"I will probably need to be on medication for the rest of my life."

"I am at high risk for post-traumatic stress disorder because I have acute stress disorder."

Answer and Explanation

Correct Answer : B,E,F

B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.

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Correct Answer is C

Explanation

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

A. Diarrhea and flatulence. B. Muscle pain. C. Abdominal cramps. D. Altered taste.

Correct Answer is B

Explanation

Rationale

A. Diarrhea and flatulence are common gastrointestinal side effects of statin medications like lovastatin. While uncomfortable for the client, these symptoms are typically not serious and do not require immediate follow-up unless severe or persistent.

B. Muscle pain, also known as myalgia, is a potential side effect of statin therapy. In some cases, statins can cause muscle inflammation (myositis) or more severe muscle breakdown (rhabdomyolysis), which can lead to serious complications such as kidney damage. If a client reports new or worsening muscle pain, especially if accompanied by weakness, tenderness, or dark urine, it requires immediate follow-up to assess for these potential complications.

C. Abdominal cramps can occur as a gastrointestinal side effect of statins but are generally not considered a serious adverse reaction. They may improve with time or adjustments in diet or medication administration timing.

D. Altered taste, such as a metallic taste, is a less common side effect of statin therapy. While it can be bothersome, it is usually not serious and does not typically require immediate follow-up unless severe or persistent.

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Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is C

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is B

Explanation

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

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?

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.