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 D

Explanation

A. While fluid restriction may be necessary for some clients with heart failure, a general fluid
intake limit of 1,500 mL daily may not be appropriate for all clients. Fluid restriction should be individualized based on the client's clinical status and recommended by the healthcare provider.
B. While a balanced diet, including adequate protein intake, is important for overall health, there is no specific evidence to suggest that a high protein diet is necessary for clients with heart
failure. Dietary recommendations should be individualized based on the client's nutritional needs and medical condition.
C. Range of motion exercises may be beneficial for maintaining joint mobility, but they are not specifically related to managing heart failure symptoms or preventing exacerbations.
D. Weighing every morning is an important self-monitoring strategy for clients with heart failure to assess for fluid retention. Sudden weight gain may indicate fluid accumulation, which can be an early sign of worsening heart failure. Daily weight monitoring allows for early intervention and adjustment of treatment as needed.

A. Clients who incurred disease complications promptly received rehabilitation. B. More than half of at-risk clients were diagnosed early in their disease process. C. Average client scores improved on specific risk factor knowledge tests. D. New screening protocols were developed, validated, and implemented.

Correct Answer is C

Explanation

A. Clients who incurred disease complications promptly received rehabilitation: This outcome suggests that the focus is on secondary prevention rather than primary prevention.
B. More than half of at-risk clients were diagnosed early in their disease process: While early diagnosis is important, it is not a direct measure of the effectiveness of a primary prevention program.
C. Average client scores improved on specific risk factor knowledge tests: This outcome indicates that clients are better informed about risk factors for sexually transmitted diseases, suggesting that the primary prevention program has been effective in increasing awareness and knowledge.
D. New screening protocols were developed, validated, and implemented: While developing new screening protocols may be beneficial, it does not directly measure the effectiveness of the
primary prevention program.

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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

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?

Correct Answer is D

Explanation

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center. Which outcome indicates that the program was effective?

Correct Answer is C

Explanation

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

A client receives a prescription for loratadine suspension 10 mg PO once a day. The bottle is labeled, "Loratadine for Oral Suspension, 5 mg per 5 mL." How many teaspoons should the nurse instruct the client to take? (Enter numerical value only.)

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

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.