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"}}

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.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale:
Encouraging the mother to write her thoughts and feelings in a journal is a constructive and therapeutic response. It provides an outlet for the mother to express her emotions and can be a helpful tool for coping with the challenges she is facing.

Choice B rationale:
Determining if the mother has other children who do not have developmental disabilities may be relevant to understanding her support system and family dynamics, but it does not directly address her current emotional distress.

Choice C rationale:
Reassuring the mother that her child will achieve some growth and development milestones may not be appropriate in this situation, as the child's disabilities are described as profound, and it is uncertain what milestones the child will reach. Providing false hope may not be helpful and could be misleading.

Choice D rationale:
Asking the mother if she has ever thought about harming herself or her child is an important inquiry related to her emotional state and the potential risk of harm. However, it should follow the initial response of encouraging her to express her thoughts and feelings in a journal.

A. Sweet potatoes. B. Spinach salad. C. Bananas. D. Fish.

Correct Answer is B

Explanation

Choice A rationale:
Sweet potatoes are not typically high in oxalates and are generally considered safe to consume in moderation for individuals with calcium oxalate renal stones.

Choice B rationale:
Spinach is high in oxalates, which can contribute to the formation of calcium oxalate renal stones. Therefore, the client should be instructed to avoid spinach and foods high in oxalates.

Choice C rationale:
Bananas are generally low in oxalates and are not likely to be a significant contributor to the formation of calcium oxalate renal stones. They are safe for most individuals to consume.

Choice D rationale:
Fish is generally not high in oxalates and is not a major concern for individuals with calcium oxalate renal stones. However, it's essential to maintain an overall balanced diet and stay hydrated to prevent stone formation.

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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

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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 History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

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

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?

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

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

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