Patient Data

Exhibits

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

Based on the client's history, physical and laboratory findings, the priority need will be to treat
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, in addition, the client will need interventions to manage complications, especially
dropdown
.

Answer and Explanation

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

Rationale for correct choices:

• Infection: The client presents with redness, warmth, swelling, and pain in the left lower leg, accompanied by a small cut and a history of type 2 diabetes. These findings, along with elevated temperature and glucose, indicate a bacterial skin infection requiring prompt treatment with antibiotics to prevent progression.

• Sepsis: Older adults with diabetes and chronic comorbidities are at high risk for systemic infection. The client’s generalized muscle aches, fever, and elevated glucose may indicate early systemic involvement. Interventions to prevent sepsis, such as timely IV antibiotics, monitoring vital signs, and laboratory markers (e.g., WBC, lactate), are crucial to reduce life-threatening complications.

Rationale for incorrect choices:

• Congestive heart failure: While the client has a history of heart failure, the acute presentation of erythema, warmth, and localized swelling suggests infection rather than fluid overload as the priority concern. CHF management is important but secondary in this scenario.

• Kidney disease: Stage 3a chronic kidney disease is a chronic condition and does not explain the acute signs of infection. Monitoring kidney function is important for medication dosing, but it is not the immediate priority.

• Hyperglycemia: The client’s blood glucose is elevated at 252 mg/dL, likely worsened by stress and infection. Hyperglycemia requires monitoring and management, but the underlying infection poses a more immediate threat to health.

• Deep vein thrombosis: DVT can cause leg swelling and pain, but the presence of erythema, warmth, and a break in the skin indicates cellulitis rather than thrombus formation. DVT prevention may be part of ongoing care but is not the priority in this acute presentation.

• Peripheral neuropathy: The client has baseline neuropathy contributing to bilateral leg discomfort, but it does not explain the acute swelling, redness, and warmth. Pain management may be necessary, but infection treatment is urgent.

• Edema: Edema is a symptom present in several chronic conditions, including CHF and PVD, but in this case, localized edema is part of the infection process. Addressing the infection takes priority over general edema management.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Plumb line test indicates fetal position curvature: This assessment is used to evaluate spinal alignment and posture, not hip integrity. It does not explain asymmetrical buttocks in a newborn.

B. Ortolani maneuver causing a click at the hip joint: A positive Ortolani sign (a “click” or “clunk”) indicates hip dysplasia or subluxation. This finding is significant and should be reported to the healthcare provider for further evaluation and management.

C. Babinski test that reveals fanning out of toes: The Babinski reflex is normal in newborns and does not indicate musculoskeletal abnormality. It is unrelated to asymmetrical buttocks.

D. Moro test precipitating a startle response: The Moro reflex is a normal newborn response and does not indicate hip instability or asymmetry in the buttocks.

A. Advise the UAP to stop providing care so the nurse can assess the client's condition. B. Determine why the UAP did not notify the nurse of the change in the client's condition. C. Ask the UAP to position the client so the oral medications can be administered. D. Explain to the UAP that changes in a client's condition should be reported immediately.

Correct Answer is A

Explanation

A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.

B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.

C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.

D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.

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Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

Correct Answer is A

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?

Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?

Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?

The nurse is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?