For which of the following behaviors would limit setting be most essential? The client:

displays hypervigilance and refuses to attend unit activities.

is flirtatious toward staff members of the opposite sex.

urges a suspicious client to hit anyone who stares at him.

clings to the nurse and asks for advice about inconsequential matters.

Answer and Explanation

The Correct Answer is C

Choice A Reason
Limit setting may be helpful for a client who displays hypervigilance and refuses to attend unit activities, as it can provide clear expectations and help reduce anxiety. However, this behavior does not pose an immediate risk to the safety of others, making limit setting less essential compared to behaviors that could lead to harm.

Choice B Reason
While being flirtatious toward staff members may be inappropriate and require intervention, it is typically addressed through professional boundaries rather than limit setting. Limit setting in this context would involve clarifying acceptable behaviors within the therapeutic relationship.

Choice C Reason
Urging another client to commit violence is a behavior that necessitates immediate limit setting. This behavior poses a direct threat to the safety of others and disrupts the therapeutic environment. Limit setting here would involve immediate intervention to prevent harm and to maintain a safe environment for all clients.

Choice D Reason
A client who clings to the nurse and seeks advice on inconsequential matters may benefit from limit setting to encourage independence and appropriate use of staff time. However, this behavior is not as disruptive or dangerous as inciting violence, making it a lower priority for limit setting.

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Correct Answer is C

Explanation

Choice A Reason:
A side-lying position with the head elevated may provide some comfort but is not the most effective position for reducing the work of breathing in emphysema patients. This position does not maximize lung expansion or aid in the optimal use of respiratory muscles.

Choice B Reason:
The Trendelenburg position, where the body is laid flat on the back with the feet higher than the head, is not recommended for emphysema patients as it can increase the pressure on the diaphragm, making breathing more difficult.

Choice C Reason:
Leaning over the bedside table, often referred to as the tripod position, is beneficial for emphysema patients. This position allows for the optimal use of respiratory muscles and helps to reduce the work of breathing by supporting the arms and allowing the shoulder girdle muscles to assist in the breathing process.

Choice D Reason:
Fowler's position, where the patient is seated with the legs either bent or straight out in front, may not be as effective as the tripod position for emphysema patients. While it does allow for better lung expansion than lying flat, it does not provide the same level of support for the respiratory muscles as leaning forward does.

A. Blood pressure of 120/80 mmHg. B. Serum potassium of 5.5 mEq/L. C. Heart rate of 80 beats per minute. D. Respiration rate of 16 breaths per minute.

Correct Answer is B

Explanation

Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.

Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.

Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

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For which of the following behaviors would limit setting be most essential? The client:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with emphysema states that it is uncomfortable to sit in a semi-Fowler's position. In order to best decrease the work of breathing, the nurse should assist the client to:

Correct Answer is C

Explanation

A client is prescribed lisinopril 20 mg PO daily for the treatment of hypertension. Which finding would alert the nurse that a side effect of the medication has occurred?

Correct Answer is B

Explanation

The nurse is sitting with a client diagnosed with schizophrenia, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say:

A nurse is assessing a client newly diagnosed with early-onset osteoarthritis. Which manifestation should the nurse expect?

A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. Which finding should the nurse recognize as the priority? The client reports:

The nurse is providing discharge teaching to a client newly diagnosed with hypertension. Which food item(s) should the nurse instruct the client to avoid in order to assist In controlling the blood pressure? (SELECT ALL THAT APPLY)

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