The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.
Complete the following sentence by using the list of options.
The nurse should first plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale:
• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.
• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.
• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.
• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.
• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.
• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. “I should try to focus on pleasant images to help replace stressful and negative feelings I have.”: This describes guided imagery, a relaxation technique that uses visualization to reduce stress. While helpful, it does not involve the cognitive restructuring.
B. “I will use my smartwatch to monitor my sleep and heart rate to assist me with gaining voluntary control over my stress.”: This reflects biofeedback, where physiological responses are tracked and managed through conscious control. It involves physical awareness, not cognitive reinterpretation of stress.
C. "I should reassess the situation and change my perceptions of stress by replacing irrational beliefs.”: This is cognitive reframing, a technique that helps clients identify and challenge distorted thinking and replace it with more rational, constructive thoughts to alter their emotional responses to stress.
D. "I will tense my muscles for 8 seconds and then relax them to release the tension caused by my stress.”: This refers to progressive muscle relaxation, which targets physical symptoms of stress rather than the cognitive processes addressed in cognitive reframing.
Correct Answer is D
Explanation
Rationale:
A. Mix the medication in juice prior to administration: Montelukast can be mixed with soft foods like applesauce, but mixing it in juice is not specifically recommended due to potential taste masking and dosing accuracy issues. Instructions should follow the manufacturer’s guidelines.
B. Administer the medication when the toddler has an acute asthma attack: Montelukast is a maintenance medication used to prevent asthma symptoms and is not effective for treating acute asthma attacks. A rescue inhaler like albuterol should be used during acute episodes.
C. Provide an additional dose of the medication prior to physical activity: Montelukast is not typically dosed in response to physical activity. While it can help prevent exercise-induced bronchospasm, it should be taken once daily in the evening, not additionally before exertion.
D. Administer the medication to the toddler each evening: Montelukast is prescribed as a once-daily maintenance therapy and is most effective when given in the evening. This helps maintain consistent blood levels and prevents nighttime asthma symptoms.
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