Patient Data

Exhibits

Drag one condition and one client finding to complete the sentence(s).

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of
as evidenced by
.

neurological defects as evidenced by

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

The client presents with facial droop and garbled speech, which are classic symptoms of a stroke. The CT scan ruled out intracranial hemorrhage, aligning with ischemic stroke symptoms. The neurological assessment indicated left-sided facial droop, diminished hand grasp strength, and garbled speech, all of which are consistent with neurological deficits typically seen in a stroke.

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Correct Answer is D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

A. Place all client belongings out of reach B. Instruct the client to call before getting up C. Initiate use of the bed alarm D. Complete a swallow study before giving anything by mouth E. Place the client in a room near the elevator F. Provide a call button kept within reach

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

A. placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B. Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C. Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D. Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E. Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F. Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

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Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of as evidenced by. neurological defects as evidenced by

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Naxlex Comprehensive Predictor Exams

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is D

Explanation

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of as evidenced by. neurological defects as evidenced by

Patient Data

Exhibits

Drag one condition and one client finding to complete the sentence(s).

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of
as evidenced by
.

neurological defects as evidenced by