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.

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Correct Answer is A

Explanation

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

A. The client should be aware of the signs and symptoms of his illness. B. The client should plan to participate in group or individual therapy while at college. C. Despite the illness, the client should be able to live away from home. D. The client's serum lithium levels should be routinely evaluated.

Correct Answer is D

Explanation

Choice A rationale:
While it's important for the client to be aware of the signs and symptoms of their illness, medication monitoring is a more immediate concern.
Choice B rationale:
Participating in therapy can be beneficial, but it's not the most critical information to provide in this context.
Choice C rationale:
Living away from home is possible for many individuals with bipolar disorder, but medication management is a higher priority.
Choice D rationale:
Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity in individuals taking lithium carbonate for bipolar disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

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?

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?