Exhibits
Drag from the options to complete the sentence
After listening to the client's symptoms, the nurse realizes that she likely has related to
Options for 1
(separation anxiety, acute stress disorder, phobia, hallucinations)
Options for 2
(undiagnosed mental health disorder, traumatic stress exposure, side effects of medication, overstimulation)
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Options for 1:
A) Incorrect- Separation anxiety: This choice is incorrect because separation anxiety typically refers to a fear or distress about being separated from loved ones or familiar environments. It's often seen in children and can involve symptoms like excessive worry when separated from attachment figures. The client's symptoms do not align with separation anxiety; they are more related to the traumatic event itself.
B) Correct- Acute stress disorder: The client's symptoms of distressing thoughts, memories of the traumatic event, and difficulty coping with the event are indicative of acute stress disorder. This disorder occurs in response to a traumatic event and involves various symptoms like intrusive thoughts, avoidance behavior, negative mood, and hyperarousal.
C) Incorrect- Phobia: This choice is incorrect because a phobia is an intense and irrational fear of a specific object, situation, or activity. The client's symptoms involve distressing thoughts, memories, and difficulty sleeping related to the traumatic event of her house collapsing. These symptoms are not indicative of a specific phobia but rather a broader stress reaction.
D) Incorrect- Hallucinations: This choice is incorrect because hallucinations refer to sensory perceptions (like hearing voices or seeing things) that are not based in reality. The client is not reporting hallucinations; instead, she is describing distressing thoughts and memories related to the traumatic event.
Options for 2:
A) Incorrect- Undiagnosed mental health disorder: This choice is incorrect because while the client may indeed have an underlying mental health concern, the specific symptoms described in the scenario are more indicative of a reaction to a traumatic event rather than a pre-existing undiagnosed disorder.
B) Correct- traumatic stress exposure: in this case, is the client's experience of her house collapsing during a hurricane.
C) Incorrect- Side effects of medication: This choice is incorrect because the client's symptoms are primarily related to the traumatic event and her emotional response to it. There is no indication in the scenario that her symptoms are a result of medication side effects.
D) Incorrect- Overstimulation: This choice is incorrect because overstimulation typically refers to being overwhelmed by excessive sensory input. While the client does mention a preference for a quieter area, her symptoms are more about distressing thoughts, memories, and difficulty sleeping due to the traumatic event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client's serum potassium level is elevated at 6.0 mEq/L (6.0 mmol/L), which is above the normal reference range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.
While monitoring glucose levels before and after meals is important for clients receiving insulin therapy, in this scenario, the primary concern is the elevated potassium level.
The nurse should prioritize frequent assessment of the serum potassium level to guide appropriate management and prevent complications associated with hyperkalemia.
Monitoring and documenting strict intake and output are important for assessing fluid balance and renal function, but in this case, the elevated potassium level takes precedence as it poses a more immediate risk to the client's well-being.
Obtaining a 12-lead electrocardiogram (ECG) daily may be indicated in some cases of hyperkalemia, as certain ECG changes can be associated with elevated potassium levels. However, the more critical aspect is monitoring the potassium level itself, as ECG changes can occur rapidly and may not always be detectable on a daily basis.
Correct Answer is A
Explanation
Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.
Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.
Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.
Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.
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