Exhibits

For each assessment finding, explain whether the actions taken were effective or ineffective.

DenIes cramps, weakness, ornausea

BP 116/68 mm Hg, HR 75 bpm

Potasslum level 3.6 mEq/L3.6mmol/L)

Verbalizes commitment to dialysisappointments

Client states that she will need to resume her Lisinopril to control blood pressure

Client is eager to add dark green vegetables and potatoes to her diet

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

a) Denies cramps, weakness, or nausea

This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.

b) BP 116/68 mm Hg, HR 75 bpm

This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.

c) Potassium level 3.6 mEq/L (3.6 mmol/L)

This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.

d) Verbalizes commitment to dialysis appointments

This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.

e) Client states that she will need to resume her Lisinopril to control blood pressure

This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.

f) Client is eager to add dark green vegetables and potatoes to her diet

This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect because consuming a high protein diet is not a recommended strategy to reduce risk factors for BPH. In fact, some studies have suggested that a high protein intake may increase the risk of BPH by stimulating the production of insulin-like growth factor-1 (IGF-1), which may promote prostate growth.

Choice B reason: This is incorrect because obtaining a prostate-specific antigen blood level test is not a preventive measure for BPH, but rather a diagnostic tool to detect prostate cancer or monitor its treatment. Prostate-specific antigen (PSA) is a protein produced by the prostate gland that can be elevated in both BPH and prostate cancer. However, PSA levels alone cannot distinguish between these two conditions and need to be interpreted along with other factors, such as age, race, family history, and digital rectal examination.

Choice C reason: This is incorrect because taking vitamin supplements is not a proven method to reduce risk factors for BPH. While some vitamins, such as vitamin D and vitamin E, may have some beneficial effects on prostate health, there is not enough evidence to support their use as preventive agents for BPH. Moreover, some vitamins, such as vitamin A and vitamin B6, may have adverse effects on prostate health and increase the risk of BPH or prostate cancer.

Choice D reason: This is correct because increasing physical activity is a helpful way to reduce risk factors for BPH. Physical activity can help maintain a healthy weight, lower blood pressure, improve blood circulation, reduce inflammation, and regulate hormone levels. All of these factors can contribute to preventing or delaying the development of BPH.

A. Canned vegetables with additional table salt. B. Pasta with herbal butter and no meat sauce. C. Citrus fruit and melon with a salt substitute. D. Whole milk and daily servings of ice cream.

Correct Answer is D

Explanation

Choice A reason: Canned vegetables with additional table salt are not a good choice for someone with cholecystitis, because they are high in sodium, which can increase fluid retention and inflammation. However, this choice is not eliminated by the client, so it does not indicate successful teaching.

Choice B reason: Pasta with herbal butter and no meat sauce is a good choice for someone with cholecystitis, because it is low in fat and protein, which can trigger gallbladder contractions and pain. This choice is not eliminated by the client, so it does not indicate successful teaching.

Choice C reason: Citrus fruit and melon with a salt substitute are also good choices for someone with cholecystitis, because they are high in vitamin C and water, which can help dissolve gallstones and prevent infection. This choice is not eliminated by the client, so it does not indicate successful teaching.

Choice D reason: Whole milk and daily servings of ice cream are bad choices for someone with cholecystitis, because they are high in fat and cholesterol, which can worsen gallbladder inflammation and increase the risk of gallstone formation. This choice is eliminated by the client, so it indicates successful teaching.

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Exhibits For each assessment finding, explain whether the actions taken were effective or ineffective.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?

Correct Answer is D

Explanation

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Correct Answer is D

Explanation

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Exhibits The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

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Exhibits

For each assessment finding, explain whether the actions taken were effective or ineffective.