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Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

Acknowledge feelings of anxiety.

Weigh the client twice weekly.

Encourage exercise.

Provide family education on the condition.

Monitor trips to the restroom.

Allow for menu deviations.

Set precise mealtimes.

Answer and Explanation

Correct Answer : A,B,D,E,G

A. Acknowledge feelings of anxiety: The client's neurological assessment indicates agitation, and acknowledging this can help in addressing any underlying anxiety.
B. Weigh the client twice weekly: Given the client's low BMI and the mother's concern about her weight, regular monitoring is necessary.
C. Encourage exercise: While exercise is generally healthy, the client's current bradycardia and low BMI suggest that immediate physical exertion may not be advisable without medical
supervision.
D. Provide family education on the condition: The client's mother's concern and the client's defensiveness about her weight indicate a need for family education.
E. Monitor trips to the restroom: Monitoring is important to ensure the client is not engaging in behaviors that could further compromise her health, such as purging.
F. Allow for menu deviations is incorrect. Allowing menu deviations can enable the client to avoid certain foods, which reinforces disordered eating behaviors. Structured, balanced meals are essential for recovery.

G. Set precise mealtimes is correct because establishing structured mealtimes promotes consistency and reduces anxiety related to eating. This helps the client develop healthier eating patterns and decreases the urge to binge or purge.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Connecting the nasogastric tube to high continuous suction without further assessment or intervention is not appropriate and could exacerbate the situation.
B. Clamping the nasogastric tube and contacting the healthcare provider is the correct action. "Coffee ground" drainage can indicate the presence of blood in the stomach, which may require further evaluation and intervention by the healthcare provider.
C. Connecting the nasogastric tube to suction as prescribed without addressing the presence of "coffee ground" drainage is not appropriate. It's important to assess the significance of this finding before proceeding with suctioning.
D. Immediately removing and then reinserting the nasogastric tube may not be necessary and could increase the risk of trauma or complications. It's important to assess the situation further and involve the healthcare provider in decision-making.

A. Loss of sensation to the left lower extremity. B. Sloughing tissue around wound edges. C. Weeping serosanguineous fluid from wounds. D. Reporting increased pain and pressure. E. Change in the quality of the peripheral pulses.

Correct Answer is ["A","D","E"]

Explanation

A. Loss of sensation to the left lower extremity warrants immediate intervention as it may indicate nerve damage, impaired circulation, or compartment syndrome. These findings require urgent evaluation to prevent permanent damage.

B. Sloughing tissue around wound edges is a common finding in burn injuries during the healing process. While it requires monitoring and proper wound care, it does not necessitate immediate intervention unless accompanied by signs of infection.

C. Weeping serosanguineous fluid from wounds is expected in burn injuries, especially in the early stages of healing. This finding does not indicate an acute complication.

D. Reporting increased pain and pressure is a critical finding as it may indicate compartment syndrome, a condition where increased pressure within a muscle compartment impairs circulation and tissue viability. Immediate intervention is required to prevent further complications.

E. A change in the quality of peripheral pulses is an alarming finding as it suggests impaired circulation, potentially due to edema, vascular compromise, or compartment syndrome. This requires prompt assessment and action to restore adequate blood flow.

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Exhibits Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

Correct Answer is B

Explanation

When caring for a client with full-thickness burns to both lower extremities, what assessment finding(s) warrant immediate intervention by the nurse? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

A client at 10-weeks gestation reports a maculopapular rash on the face, fever, malaise, sore throat, and lymphadenopathy. Which laboratory result should the nurse review?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Exhibits Review History and Physical, and laboratory results. Based on the finding, indicate whether the finding represents a modifiable risk factor, a non modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.