Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night.
Which intervention is most important for the nurse to implement?

Ask the spouse if the client seems to be depressed.

Tell the spouse to wait outside so the client can be assessed for depression.

Explain that depression often occurs after a life-threatening experience.

Encourage the client to further describe his feelings.

Answer and Explanation

The Correct Answer is D

A.   Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B.   While privacy is important, the spouse can often provide additional valuable information.
C.   Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D.   Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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Correct Answer is A

Explanation

A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.

A. Ask the spouse if the client seems to be depressed. B. Tell the spouse to wait outside so the client can be assessed for depression. C. Explain that depression often occurs after a life-threatening experience. D. Encourage the client to further describe his feelings.

Correct Answer is D

Explanation

A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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Naxlex Comprehensive Predictor Exams

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choice(s) included on the client's list should the nurse encourage? Select all that apply.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.