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 A

Explanation

Rationale

A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.

B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.

C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.

D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.

A. Notify information services department of the situation. B. Print electronic medical record (EMR) from backup server. C. Wait for notification that the system has been rebooted. D. Identify information as late entry in the record.

Correct Answer is A

Explanation

Rationale

A. Informing the information services department allows them to be aware of the issue promptly. They can then investigate the cause of the system failure and initiate appropriate measures to restore the system. It's important to involve IT professionals who are responsible for maintaining and troubleshooting the computer system.

B. While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.

C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.

D. Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.

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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

Correct Answer is A

Explanation

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is A

Explanation

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The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

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A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Exhibits

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