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 B
Explanation
Rationale:
A. "I should be able to follow my normal routine after the staples are removed from my incision.” Normal activities should be resumed gradually; simply removing staples does not mean the incision and abdominal muscles have fully healed.
B. "I will ask my partner to perform household chores until my incision is healed." Delegating strenuous tasks supports proper healing and prevents strain on the incision site, reflecting appropriate understanding of postpartum activity restrictions.
C. "I will wait 4 to 6 weeks to perform kegel exercises." Kegel exercises can usually begin soon after delivery to strengthen pelvic floor muscles and are not delayed for several weeks unless specifically advised.
D. "I will maintain modified bed rest for the first 48 to 72 hours at home." While initial rest is important, prolonged bed rest can increase the risk of complications like blood clots. Gradual ambulation is encouraged to promote circulation and recovery.
Correct Answer is B
Explanation
Rationale:
A. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by reducing social interaction and support. Clients with major depressive disorder benefit more from structured, supportive environments that encourage engagement.
B. Encourage the client to use positive self-talk: Promoting positive self-talk helps challenge negative thought patterns common in depression. This cognitive-behavioral strategy can improve mood, self-esteem, and overall coping ability.
C. Offer the client low-protein snacks throughout the day: Nutritional support is important, but there is no specific reason to offer low-protein snacks for depression. A balanced diet with adequate protein may better support brain function and mood regulation.
D. Suggest the client exercise before going to bed: Regular exercise is beneficial for managing depression, but exercising before bedtime can disrupt sleep patterns. Physical activity is better scheduled earlier in the day to promote restfulness at night.
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