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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm. B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation. C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation. D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Correct Answer is C

Explanation

Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.

Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.

Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.

Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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?

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

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

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?

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?

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

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