Exhibits

The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).

Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.

Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.

Cerebral edema

Acute asphyxia

Hypertension

Respiratory distress

Hyperthermia

Subdural hemorrhage

Answer and Explanation

Correct Answer : A,B,D,F

A)   Cerebral edema: Brain injury or trauma can lead to swelling and increased intracranial pressure.
B)   Correct- Near- drowning causes acute asphyxia because it prevents the person from breathing in oxygen and exhaling carbon dioxide. Asphyxia is a condition where the body is deprived of oxygen, which can lead to loss of consciousness, brain injury, or death.
C)   Incorrect- Hypertension is not a common complication following near-drowning. The focus should be on potential brain injuries and respiratory distress.
D)   Correct- Near-drowning can lead to aspiration of water or other substances, which can result in respiratory distress.
E)   Incorrect- hyperthermia is not likely to occur in this case because the child was exposed to cold water.
F)   Correct- Head trauma can lead to bleeding within the brain, such as a subdural hemorrhage.

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Correct Answer is C

Explanation

A) Incorrect- While providing comfort measures like blankets and warm drinks can help the client feel more comfortable, they do not address the underlying thyroid hormone imbalance.
B) Incorrect- Hemoglobin level is not directly related to the client's symptoms or the thyroid hormone imbalance. Monitoring hemoglobin is important in assessing anemia but is not the priority in this case.
C) Correct- The client's symptoms (raspy voice, cold intolerance, fatigue) along with an elevated TSH and low T3 and T4 levels suggest hypothyroidism. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Administering the prescribed dose of levothyroxine is crucial to address the thyroid hormone imbalance and alleviate the symptoms.
D. Incorrect- Non-pitting edema is not a common symptom of hypothyroidism. The client's symptoms and lab results are more indicative of hypothyroidism, and addressing the thyroid hormone imbalance is the priority.

A. Use firmness and direct the client to sit for awhile. B. Suggest to the client that he take a walk. C. Move the client to a quiet place on the unit. D. Encourage the client to use the punching bag

Correct Answer is C

Explanation

Delusions and loss of control can be distressing for the client and potentially disruptive to the unit environment. Moving the client to a quiet place helps create a calm and less stimulating environment, which can help reduce agitation and promote a sense of safety and security.

Using firmness and directing the client to sit for a while may escalate the situation and increase the client's distress. It is important to approach the client with empathy and provide a supportive environment rather than exerting control through firmness.

Suggesting the client take a walk or encouraging the client to use a punching bag may not be appropriate if the client is already displaying signs of agitation and losing control. These interventions may not address the underlying causes of the delusions and could potentially worsen the situation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take?

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?