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. Instituting an exercise plan is important for overall health and may be part of the client's
treatment plan. However, the primary focus initially should be on addressing disordered eating behaviors and achieving a balanced diet.
B. Regulating food portions is a crucial goal for individuals with binge eating disorder to help establish healthier eating habits and prevent episodes of overeating.
C. Obtaining satisfaction with appearance may be a long-term goal for some individuals with binge eating disorder, but it is not typically the first goal addressed in treatment.
D. Achieving a steady weight loss may not be appropriate for all individuals with binge eating disorder, as the focus should be on promoting a healthy relationship with food rather than solely on weight loss.

A. Swollen feet and ankles. B. Blood tinged sputum. C. Rapid, regular heart rate. D. Elevated blood pressure.

Correct Answer is B

Explanation

A. Swollen feet and ankles: While swelling can indicate fluid retention, it may not necessarily warrant immediate intervention unless it is severe or accompanied by other concerning symptoms.

B. Blood-tinged sputum is the most concerning finding because it suggests pulmonary congestion or pulmonary edema, which can occur due to increased pressure in the pulmonary circulation secondary to mitral valve stenosis. This could indicate acute decompensation of the client’s condition, requiring immediate intervention to prevent respiratory compromise or worsening heart failure.

C. Rapid, regular heart rate (e.g., sinus tachycardia) is a compensatory response to reduced cardiac output and increased demand. While it warrants monitoring and potential treatment, it is not as critical as the presence of blood-tinged sputum, which signals acute pulmonary involvement

D. Elevated blood pressure: While elevated blood pressure may indicate increased cardiac workload, rapid, irregular heart rate is a more immediate concern in this context due to its potential to cause complications such as thromboembolism

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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

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

Correct Answer is B

Explanation

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

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?

The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

The nurse is conducting Intake Interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

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?

A client is being discharged home after being treated for heart failure (HF. Which instruction should the nurse include in this client's discharge teaching plan?

Exhibits What can the nurse do to help the parents to decrease their anxiety? 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.