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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Presence of cough

Absence of gag reflex

Respiratory rate of 6 breaths per minute

Urine output 90 mL/hour

Heart rate 70 beats per minute

Capillary refill less than 3 seconds

Answer and Explanation

Correct Answer : B,C

A. The presence of a cough is expected as a protective reflex and does not delay transfer.

B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.

C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.

D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.

E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.

F. Capillary refill less than 3 seconds is normal and does not delay the transfer.

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Correct Answer is C

Explanation

A. Persistent low-grade depression without hypomania is not typical of bipolar II disorder, as hypomanic episodes are a key feature of the disorder.

B. Psychosis is more common during full manic episodes, typically seen in bipolar I disorder, not bipolar II.

C. Bipolar II disorder is characterized by hypomanic episodes that alternate with major depressive episodes. Hypomania is a less severe form of mania, and individuals with bipolar II do not experience full manic episodes as in bipolar I.

D. Severe manic episodes are characteristic of bipolar I disorder, not bipolar II, which involves hypomanic episodes instead.

A. Assist the client in developing a structured schedule for activities of daily living B. Provide education about the irrationality of the behavior C. Collaborate with the client to set realistic goals for behavior change D. Encourage the client to resist the urge to rearrange items

Correct Answer is C

Explanation

A. A structured schedule may help with overall daily functioning, but it does not specifically address the compulsive behavior.

B. Educating the client about the irrationality of the behavior is unlikely to reduce the compulsions, as this is a hallmark of OCD, where the individual is often unable to control the urges despite understanding their irrationality.

C. Collaborating with the client to set realistic, gradual goals for changing the compulsive behavior is key in treating OCD. This approach allows the client to have input into their treatment plan and promotes realistic, achievable progress.

D. Encouraging the client to resist the urge to rearrange items without providing a structured approach may lead to increased anxiety and frustration. Gradual exposure and behavior modification are more effective.

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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with bipolar II disorder is most likely to experience:

Correct Answer is C

Explanation

A 35-year-old client with OCD spends several hours each day arranging and rearranging household items in a specific order. The client becomes extremely distressed if the items are not arranged correctly. Which nursing intervention is most appropriate?

Correct Answer is C

Explanation

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