The nurse reviews the Nurses' Notes from Day 1 at 1100.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's
dropdown
followed by the client
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for correct choices:

Electrolyte imbalance: The client’s potassium level of 3.0 mEq/L is critically low, contributing to premature ventricular contractions and orthostatic hypotension. These abnormalities place the client at immediate risk for cardiac dysrhythmias and require urgent correction to prevent life-threatening complications.
View of body: The client voices fear of gaining weight and fixates on food, which are indicators of distorted self-perception. This impaired view of the body is a central feature of bulimia nervosa and needs to be addressed during psychotherapy once the client is medically stabilized.

Rationale for incorrect choices:

Impaired body image: While body image concerns are common in eating disorders, this option is more general. “View of body” better captures the client’s psychological distortion and allows for more precise therapeutic interventions that address the cognitive roots of the disorder.
Impaired coping: The client engages in maladaptive coping strategies like bingeing and purging. However, these behaviors are secondary to deeper distortions in self-image and medical instability. Coping can be addressed later in the treatment process once safety is ensured.
History of anxiety: Anxiety is part of the client's long-standing history but is not causing the immediate physical risk. Addressing acute electrolyte disturbances and body image distortion takes precedence over chronic anxiety in this clinical setting.
Obsession with food: Although the client’s persistent thoughts about food are important, they are symptoms driven by distorted body perception. Treating the underlying belief system about body image is more foundational and effective in resolving food-related obsessions.

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Correct Answer is B

Explanation

Rationale:

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing negative emotions can hinder psychological adjustment. Clients should be encouraged to express their feelings openly as part of the adaptation and coping process.

B. Suggest the client join a support group for people who have colostomies: Support groups can provide emotional reassurance, shared experiences, and practical coping strategies. Seeing others manage their stomas successfully can promote acceptance and self-confidence.

C. Instruct the client's partner to assume care of the colostomy for the client: While partner support is important, encouraging dependence may delay the client’s adjustment and self-care ability. The goal should be to promote independence and acceptance at the client’s pace.

D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: A transfer is not necessary unless the client has complex needs. Initial support, education, and emotional guidance should be provided in the current care setting.

A. Cheyne-Stokes respirations B. Restlessness C. Mottled skin D. Constricted pupils

Correct Answer is B

Explanation

Rationale:

A. Cheyne-Stokes respirations: This irregular breathing pattern is common in clients nearing end of life due to neurologic decline. It is not a direct indicator of pain and does not necessarily require pain medication unless associated with distress.

B. Restlessness: Restlessness in a palliative care client often signals unrelieved pain, discomfort, or anxiety. It is a nonverbal cue frequently observed in clients unable to communicate pain and should prompt consideration of analgesia.

C. Mottled skin: Mottling is a sign of reduced perfusion and impending death. It reflects circulatory changes but does not directly indicate pain or warrant pain medication unless accompanied by other signs of distress.

D. Constricted pupils: Pupil constriction may result from certain medications (e.g., opioids) or brainstem pressure but is not a reliable sign of pain. It does not, by itself, indicate a need for analgesic intervention.

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The nurse reviews the Nurses' Notes from Day 1 at 1100. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown followed by the client dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who has a brain tumor and is receiving palliative care. Which of the following findings indicates the nurse should administer pain medication?

Correct Answer is B

Explanation

A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto?

A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that the client is at risk for developing a surgical wound infection?

A nurse is preparing to provide a change-of-shift report. Which of the following information should the nurse include in the report?

The nurse reviews the Nurses' Notes from Day 1 at 1100.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's
dropdown
followed by the client
dropdown
.