Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Administer 2 mg of diazepam intravenously.

Induce paralysis.

Apply cooling blankets.

Apply 1 L/min oxygen.

Ensure that the antidepressant medication is discontinued

Answer and Explanation

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

Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.

Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.

The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.

The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.

If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.

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Correct Answer is D

Explanation

A. While the medication history can be relevant, it is not the most immediate assessment needed to address the confusion and possible infection.

B. The amount of serous drainage is important for wound assessment but does not directly address the cause of confusion.

C. Urinary output is useful for evaluating kidney function but may not be directly related to the client’s confusion and wound.

D. The white blood cell count is crucial for identifying an infection or inflammatory response, which could be related to both the confusion and the wound.

A. Respiratory efforts blow off excess carbon dioxide to compensate acidosis. B. Adrenergic stimulation of sweat glands that produce generalized diaphoresis. C. Urinary filtrate becomes hyperosmolar due to glucose and causes diuresis. D. Erratic electrical impulses spread across the motor cerebral cortex.

Correct Answer is A

Explanation

A. Kussmaul respirations are deep, labored breathing patterns that help blow off excess carbon dioxide to compensate for metabolic acidosis, which is common in DKA.

B. Diaphoresis is not directly related to the respiratory pattern seen in DKA.

C. Hyperosmolar diuresis explains dehydration but not the respiratory compensation.

D. Erratic electrical impulses are not related to the respiratory pattern of Kussmaul respirations.

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Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

The nurse is providing discharge instructions for a client who had an above the knee amputation (AKA) and their spouse. The client expresses fear about going home and requests to stay in the hospital one more day. Which intervention is most important for the nurse to implement?

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.