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.

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. The nurse will call the client weekly to monitor the client's blood pressure and symptoms. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain. D. The client will record episodes of angina and self-management for one week.

Correct Answer is D

Explanation

Choice A rationale:
Weekly monitoring of blood pressure and symptoms is important but does not address the specific issue of chest pain on exertion.

Choice B rationale:
Encouraging daily walking is generally a good recommendation for overall health but does not address the immediate concern of chest pain.

Choice C rationale:
Taking up to 4 nitroglycerine tablets for chest pain may provide temporary relief, but this should be done under the guidance of a healthcare provider and is not a long-term outcome.

Choice D rationale:
Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions.

View Question and Answer

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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

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 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?

Correct Answer is D

Explanation

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?

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?

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

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?

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

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

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

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