Patient data
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Client's healthcare power of attorney: While important, this information may not be
immediately relevant to the client's current condition and the reason for contacting the healthcare provider.
B. Increasing confusion of the client: This information indicates a change in the client's status and is the most pertinent to the client's current condition, warranting immediate attention.
C. Fall at home as reason for admission: While important for background information, the reason for admission is already known, and the focus of the communication should be on the client's current status.
D. Currently prescribed medications: This information is important but may not be the priority when reporting a change in the client's condition.
Correct Answer is D
Explanation
A. Difficulty staying asleep may indicate a sleep disorder or psychological stress but is not directly related to the client's diabetes mellitus or hypertension.
B. Blood pressure of 130/80 mm Hg is within the normal range for adults and does not require further follow-up unless there are specific concerns related to the client's medical history.
C. Dark yellow urine may indicate dehydration, which could be related to the client's diabetes mellitus and hypertension. However, it is not as concerning as the elevated serum creatinine
level.
D. Serum creatinine level of 1.6 mg/dL (141.44 μmol/L) is elevated above the normal range for both females and males. This finding suggests impaired kidney function, which is a significant concern for a client with a history of type 2 diabetes mellitus and hypertension. Further follow- up and evaluation are necessary to assess kidney function and determine appropriate
interventions.
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