Patient Data

Exhibits

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of
dropdown
would be explained by assessment findings of
dropdown
and
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Engage the client in non-threatening conversations: Establishing a therapeutic nurse–client relationship through simple, supportive communication helps reduce isolation, builds trust, and may encourage the client to begin expressing thoughts and feelings.

B. Encourage the client's family to visit more often: Family involvement can be beneficial, but it may not be effective if the client is withdrawn. Increasing visits without first fostering a supportive environment could overwhelm or further isolate the client.

C. Encourage the client to participate in group activities: Group activities promote social interaction but may feel intimidating or threatening for someone who has been withdrawn for weeks. Gradual re-engagement beginning with one-on-one communication is more appropriate.

D. Schedule a daily conference with the social worker: Involving the social worker can be helpful for comprehensive care planning, but this does not directly address the immediate nursing priority of engaging the client therapeutically and reducing withdrawal.

A. Chest pain B. Petechiae C. Origin typically long bone fracture D. Altered mental status E. Dyspnea F. Origin typically deep vein thrombosis G. Tachycardia

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B,B"},"F":{"answers":"B"},"G":{"answers":"A,B"}}

Explanation

• Chest pain: Blood clot embolism, especially pulmonary embolism, typically causes sudden chest pain due to obstruction of the pulmonary arteries. Fat embolism rarely causes chest pain as the primary symptom, though hypoxia may lead to discomfort. Chest pain is therefore more indicative of thrombotic embolism.

• Petechiae: Petechiae on the neck, upper chest, and conjunctiva are hallmark signs of fat embolism. They result from occlusion of dermal capillaries by fat globules and platelet aggregation. Blood clot embolism does not usually cause petechiae.

• Origin typically long bone fracture: Fat emboli commonly originate from fractures of long bones such as the femur, tibia, or pelvis. Trauma forces fat from the bone marrow into the bloodstream, creating emboli. Blood clot emboli generally do not arise from bone fractures.

• Altered mental status: Fat embolism can impair cerebral oxygenation, leading to confusion, lethargy, or agitation. This neurological involvement is a distinguishing feature of fat embolism. Blood clot embolism rarely affects mental status unless there is severe hypoxia.

• Dyspnea: Dyspnea occurs in both fat and blood clot embolism due to impaired oxygen exchange in the lungs. In fat embolism, hypoxia may develop gradually, while blood clot embolism often causes sudden shortness of breath. Both conditions require prompt respiratory support.

• Origin typically deep vein thrombosis: Blood clot emboli usually originate from deep veins in the legs or pelvis and travel to the lungs. Fat emboli are not associated with venous thrombi. Identifying the source helps differentiate between the two embolism types.

• Tachycardia: Tachycardia is a compensatory response to hypoxia or stress in both fat and blood clot embolism. It helps maintain oxygen delivery to vital organs. While nonspecific, its presence supports the need for urgent intervention in either condition.

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Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Correct Answer is A

Explanation

Patient Data Exhibits Click to indicate if the listed characteristic is consistent with a fat embolism or blood clot embolism. Each column must have at least one response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B,B"},"F":{"answers":"B"},"G":{"answers":"A,B"}}

Explanation

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

Patient Data

Exhibits

Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of
dropdown
would be explained by assessment findings of
dropdown
and
dropdown