The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male clientwith fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?
Include "Noncompliance”. as a priority problem in the client's plan of care.
Advise the UAP to re-attempt the daily weight after the client eats breakfast.
Consult with the client about the reasons for his refusal to be weighed
Calculate the client's weight based on the 24-hour fluid intake and output.
The Correct Answer is C
The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.
Choice A rationale:
Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.
Choice B rationale:
Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.
Choice C rationale:
Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.
Choice D rationale:
Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice d. Powerful craving for more.
Rationale:
Cocaine withdrawal symptoms are primarily psychological and emotional, rather than physical. While some physical symptoms may occur, such as fatigue and muscle aches, the most prominent and concerning aspects of withdrawal are intense cravings for the drug.
Here's a breakdown of the other choices and why they are not as likely:
- Choice a. Elevated energy level:Cocaine is a stimulant,so during withdrawal,a person is more likely to experiencedecreased energy and fatigue.
- Choice b. High self-esteem:Cocaine use can initially boost self-esteem,but withdrawal often leads to feelings ofdepression, anxiety, and worthlessness.
- Choice c. Euphoria:Euphoria is one of the main effects of cocaine use,but during withdrawal,the opposite occurs,with individuals experiencingdysphoria, a state of intense negative emotions.
Therefore, the intense craving for more cocaine is the most characteristic behavioral symptom exhibited during cocaine withdrawal. This craving is driven by the brain's adaptation to the drug's presence and the disruption of dopamine and other neurotransmitter systems caused by withdrawal.
Additional Notes:
- The intensity of cocaine withdrawal symptoms can vary depending on several factors,including the severity and duration of cocaine use,individual differences in brain chemistry and genetics,and the presence of co-occurring mental health conditions.
- Seeking professional help for cocaine withdrawal is crucial to manage cravings and other symptoms effectively and increase the chances of successful recovery.
Correct Answer is D
Explanation
The correct answer is choice D - Bilateral lung sounds.
Choice A rationale:
Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.
Choice B rationale:
Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.
Choice C rationale:
Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.
Choice D rationale:
Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.
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