Patient Data

Exhibits

The nurse determines the plan of care.

For each action, click to indicate whether they would be included or not included in the plan of care for the client.

Each row must have only one response option selected.

Actions

Monitor cardiac status

Educate on compliance to hemodialysis

Monitor client's vital signs

Perform a head-to-toe assessment

Monitor the client's heart rhythm

Monitor Input and Output

Monitor neuromuscular status

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"None"},"G":{"answers":"None"}}

Choice A rationale:
This is included because the client has a history of cardiovascular issues (hypertension, coronary artery disease), and the symptoms presented (fatigue, muscle cramps, tingling sensation, lightheadedness) could be related to cardiac concerns. Monitoring cardiac status helps assess for any cardiac-related issues.

Choice B rationale:
This is essential because the client's recent illness and missed dialysis sessions may have contributed to her symptoms. Ensuring the client understands the importance of compliance with hemodialysis is crucial for her overall well-being.

Choice C rationale:
Monitoring vital signs, including blood pressure, heart rate, and respiratory rate, is a fundamental aspect of assessing the client's current condition and response to treatment.

Choice D rationale:
A comprehensive head-to-toe assessment helps identify any physical signs or symptoms that may be contributing to the client's complaints and guides further evaluation and interventions.

Choice E rationale:
Given the client's history of cardiovascular disease and the complaints of chest discomfort, monitoring the heart rhythm is essential to assess for any arrhythmias or irregularities.

Choice F rationale:
Monitoring fluid intake and output is crucial, especially in clients with end-stage renal disease, as imbalances in fluid and electrolytes can exacerbate symptoms and lead to complications.

Choice G rationale:
The client's complaints of muscle cramps and tingling sensations in the arms and legs indicate potential neuromuscular involvement. Monitoring neuromuscular status helps assess these symptoms.

Choice H rationale:
There is no indication in the provided information that an immediate transfer to a telemetry unit is necessary. The client's vital signs, including heart rate and oxygen saturation, are stable at the moment. Further assessment and interventions can be carried out on the current unit before considering a transfer.

Choice I rationale:
Given the client's history of end-stage renal disease and the symptoms presented, educating her to avoid a high-potassium diet is important. High potassium levels can lead to symptoms like muscle cramps and tingling sensations, which the client is experiencing.

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Correct Answer is B

Explanation

A. Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.

B. Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.

C. Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.

D. Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.

A. Cancer screening results, anger, gastritis, daily alcohol intake. B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding. C. Efforts to cut down, annoyance with questions, guilt, and drinking as an "Eye-opener." D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Correct Answer is C

Explanation

Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.

Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."

Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.

Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.

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Patient Data Exhibits The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client. Each row must have only one response option selected. Actions

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Correct Answer is C

Explanation

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 middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

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?

Patient Data Exhibits The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client. Each row must have only one response option selected. Actions

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 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?

Patient Data

Exhibits

The nurse determines the plan of care.

For each action, click to indicate whether they would be included or not included in the plan of care for the client.

Each row must have only one response option selected.

Actions