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 A

Explanation

A. Instructing the client on the importance of notifying sexual partners is essential to prevent the spread of genital herpes and other sexually transmitted infections. Partner notification is crucial for their testing, treatment, and prevention of further transmission.
B. While it is true that cases of certain STIs are reportable to local health departments, focusing solely on reporting does not address the immediate concern of preventing transmission to sexual partners.
C. While partners without symptoms may not be infected, they could still be carriers of the virus and transmit it to others. It's important to emphasize the potential risk of transmission regardless of symptoms.
D. Counseling that most contraceptives protect against infection is inaccurate regarding STIs.
While contraceptives may prevent pregnancy, they do not provide protection against STIs like genital herpes. It's important to provide accurate information about STI prevention methods.

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 the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is A

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 with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Exhibits Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

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?

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

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

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Exhibits Review History and Physical, and laboratory results. Based on the finding, indicate whether the finding represents a modifiable risk factor, a non modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

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

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.