Patient Data

Exhibits here

The nurse is reviewing the history and physical.

Choose the most likely options for the information missing from the statement below by selecting from the list of options provided.

Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a
.

Answer and Explanation

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

Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.

Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.

Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis

Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

Choice A rationale:
Restricting visitors to family members only may not necessarily be a beneficial intervention and could potentially isolate the client further, which may not be in their best interest.

Choice B rationale:
Discussing the client's suicide plan is essential to assess the level of risk and develop strategies to keep the client safe. It allows the healthcare team to understand the severity of the client's depressive symptoms and potential suicidal ideation.

Choice C rationale:
Limiting the time allowed to play video games may be a consideration in a broader plan of care, but it is not a primary intervention for addressing depression in adolescents. The focus should be on safety, communication, and building a therapeutic relationship.

Choice D rationale:
Encouraging the client to discuss thoughts and feelings about wanting to die is crucial for therapeutic communication and assessment. It provides an opportunity for the client to express their emotions and allows for intervention and support.

Choice E rationale:
Reinforcing statements regarding a will to live and realistic plans for the future is important for building hope and motivation in the client. It can be part of a positive, strengths-based approach to treatment.

A. Bradycardia and bradypnea. B. Stimulation and dilated pupils. C. Hallucinations and delusions. D. Lethargy and depression.

Correct Answer is B

Explanation

Choice A rationale:
Cocaine is a stimulant and typically leads to increased heart rate (tachycardia) and respiratory rate (tachypnea). Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) would be atypical findings with cocaine use.

Choice B rationale:
Cocaine is a stimulant drug that typically produces effects such as increased heart rate, increased blood pressure, stimulation, euphoria, and dilated pupils. These physiological and psychological effects are common when someone has used cocaine.

Choice C rationale:
While cocaine use can cause hallucinations and paranoia during intoxication or withdrawal, these symptoms are not typically the primary manifestations. The most common initial effects are stimulation and increased alertness.
Hallucinations and delusions may occur with substance use, but they are not the most expected or specific findings for cocaine use.

Choice D rationale:
Cocaine use is associated with increased energy, euphoria, and heightened arousal. Lethargy and depression are more likely during the comedown phase or withdrawal from cocaine, rather than immediately after use.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Correct Answer is B

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?