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
dropdown
, 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.

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Correct Answer is B

Explanation

A. Heart rate 130–136 beats/minute, blood pressure 190–200/90–100 mm Hg, Kussmaul respirations: Although hypertensive and tachycardic, Kussmaul respirations are typically associated with metabolic acidosis rather than ICP. These findings are concerning but not classic for increased ICP.

B. Heart rate 55–50 beats/minute, blood pressure 160/70–194/70 mm Hg, irregular respirations: This pattern reflects Cushing’s triad—bradycardia, hypertension with widening pulse pressure, and irregular respirations—which is a hallmark sign of increased ICP and requires immediate reporting.

C. Heart rate 110–100 beats/minute, blood pressure 130/70–110/70 mm Hg, shallow respirations: Vital signs are not indicative of ICP; shallow respirations may be due to other causes, and the blood pressure trend is decreasing rather than showing hypertension with widening pulse pressure.

D. Heart rate 70–100 beats/minute, blood pressure 120/60–90/60 mm Hg, rapid respirations: These findings suggest hypotension and tachypnea, which are more indicative of hypovolemia or other systemic issues rather than increased ICP.

A. Apply warm blankets B. Administer an antipyretic C. Place ice packs around the client's head D. Check the temperature of the humidified oxygen attached to the ventilator E. Instill warm fluids in the nasogastric tube F. Microwave a pack of gauze and distribute across the body G. Administer intravenous fluids with a rapid infuser H. Use a fluid warmer for intravenous fluids

Correct Answer is ["A","D","E","G","H"]

Explanation

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: Warm IV fluids given rapidly restore circulating volume in trauma clients and also help increase core body temperature, addressing both shock and hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

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Naxlex Comprehensive Predictor Exams

Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

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.

Correct Answer is ["A","D","E","G","H"]

Explanation

Patient Data Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

The parents of an infant with chronic health conditions have cognitive challenges and diverse educational backgrounds. Which intervention(s) should the nurse implement to support them in safely administering medications to their child? Select all that apply.

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