The nurse is continuing to care for the client.

The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

The client takes 2 short naps during the day.

The client engages in quiet activities in their room.

The client slept 5 hr the previous night.

The client appears to listen to unseen others.

The client consumes 8 oz of high-calorie fluids each hour.

Answer and Explanation

Correct Answer : A,B,C,E

A. The client takes 2 short naps during the day: The ability to rest indicates decreased hyperactivity and improved regulation of sleep-wake cycles, reflecting early stabilization of manic symptoms.

B. The client engages in quiet activities in their room: Participation in calm, structured activities demonstrates reduced agitation and impulsivity, suggesting improvement in mood stability and ability to focus.

C. The client slept 5 hr the previous night: Improved sleep duration is a positive sign, as insomnia and decreased need for sleep are hallmark symptoms of mania. Achieving rest indicates partial symptom resolution.

D. The client appears to listen to unseen others: Continued auditory hallucinations indicate persistent psychotic features and do not represent improvement. These symptoms require ongoing monitoring and treatment.

E. The client consumes 8 oz of high-calorie fluids each hour: Adequate fluid and calorie intake reflects improved self-care and nutrition, which are often compromised during acute manic episodes. This is a positive indicator of functional recovery.

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Correct Answer is C

Explanation

A. Bone is exposed within the wound: Exposure of bone indicates a stage IV pressure injury, which involves full-thickness tissue loss with exposed muscle, tendon, or bone. This is more severe than stage III.

B. The skin is reddened and intact: Reddened, intact skin corresponds to a stage I pressure injury, which involves non-blanchable erythema without skin breakdown.

C. Subcutaneous fat is visible: Stage III pressure injuries involve full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. This finding is consistent with stage III classification.

D. Slough and eschar is present: While slough and eschar may be present in stage III or IV injuries, the presence alone is not sufficient to determine stage. The key characteristic for stage III is full-thickness tissue loss with visible subcutaneous fat without exposed deeper structures.

A. A 14-year-old child who eats small but frequent meals throughout the day B. A 16-year-old child who takes their proton pump inhibitor 30 min before meals C. A 6-year-old child who underwent a Nissen fundoplication and is tolerating a full liquid diet D. A 4-month-old child who is experiencing weight loss

Correct Answer is D

Explanation

A. A 14-year-old child who eats small but frequent meals throughout the day: This is an appropriate intervention for gastroesophageal reflux, as smaller, more frequent meals reduce gastric distention and minimize reflux episodes. No revision to the plan of care is needed for this child.

B. A 16-year-old child who takes their proton pump inhibitor 30 min before meals: Administering proton pump inhibitors before meals is correct because these medications are most effective when taken prior to food intake, allowing for optimal acid suppression. The current plan aligns with best practice.

C. A 6-year-old child who underwent a Nissen fundoplication and is tolerating a full liquid diet: Progressing to a full liquid diet after Nissen fundoplication is appropriate and indicates the child is tolerating postoperative dietary advancement. The plan of care is appropriate and requires no changes.

D. A 4-month-old child who is experiencing weight loss: Weight loss in an infant with gastroesophageal reflux is concerning and indicates inadequate nutrition or complications. The plan of care should be revised to address feeding adequacy, possible medical interventions, and close monitoring of growth and hydration status.

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The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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