Patient data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan.

Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema.

Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.

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Correct Answer is B

Explanation

A. Instruct in effective techniques to cleanse the glans penis: While hygiene education may be important, the client's symptoms suggest a urinary issue that needs further assessment.
B. Palpate the client's suprapubic area for distention: These symptoms are consistent with urinary retention, and palpating the suprapubic area can help assess for bladder distention.
C. Advise the client to maintain a voiding diary for one week: While a voiding diary can provide valuable information, the client's symptoms indicate a need for immediate assessment and
intervention.

D. Obtain a urine specimen for culture and sensitivity: While obtaining a urine specimen is important, it may not directly address the immediate concern of possible urinary retention

A. ambulated 100 yards (91 meters) last night and 200 yards B. pain rating of 2 C. tolerated fluids D. Alert and oriented times 4 E. Voided twice F. Respiratory WNL G. Cardiovascular WNL H. no nausea or vomiting

Correct Answer is ["A","B","C","D","E"]

Explanation

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4.

Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

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Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse of having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report what situation(s) to the school nurse? Select all that apply.

Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Patient data

Exhibits

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.