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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Free Nursing Study Resources

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

Explanation

Bruises in various stages of healing: This often indicates physical abuse, as it suggests trauma or injury from external force.

Over-sedation: This could be indicative of physical abuse if it is intentional or misuse of medications.

Depression or withdrawn behavior: These can be signs of neglect, as they may result from a lack of emotional support or social interaction.

Leaving an older adult in a public space: This is a clear indicator of abandonment, as it shows neglect of the individual's safety and well-being.

Untreated pressure injuries: These are signs of neglect, reflecting a failure to provide adequate care and prevent injuries.

Poor personal hygiene: Often a result of neglect, indicating a lack of attention to the individual's basic needs and self-care.

A. Obtain serum creatinine levels daily. B. Monitor daily sodium intake. C. Ensure client takes a diuretic every morning. D. Measure ankle circumference.

Correct Answer is C

Explanation

A. Obtaining serum creatinine levels is important but not an immediate intervention.

B. Monitoring sodium intake is essential but not the first step in acute management.

C. Administering a diuretic can help manage the fluid retention and reduce blood pressure, addressing the immediate concern of fluid overload.

D. Measuring ankle circumference is part of monitoring fluid status but does not address the immediate need to reduce fluid overload.

View Question and Answer

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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

Patient Data Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

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

Explanation

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize?

An older client with Type 2 diabetes reports experiencing leg pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

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 with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?

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.