Which client statement or behavior is most likely associated with their current condition?

The client discusses moving to Hawaii.

The client seems unemotional when talking about needing to rebuild her house.

The client expresses a desire to be in a quieter area of the unit.

The client requests sleeping medication for the night.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.

Choice B rationale

Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.

Choice C rationale

Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.

Choice D rationale

Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.

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Correct Answer is A

Explanation

Choice A rationale

The patient vomiting at home for 3 days prior to surgery is crucial information that the PACU nurse should report. This could indicate a pre-existing condition or complication that needs to be addressed in the patient’s post-operative care plan.

Choice B rationale

While the patient refusing to take ice chips despite complaining of dry mouth is an important observation, it is not as critical as the patient’s pre-operative condition (vomiting for 3 days). The refusal of ice chips could be addressed through patient education and encouragement.

Choice C rationale

The presence of peripheral pulses and full range of motion in both legs is expected and normal in a post-operative patient, unless there were complications during surgery that could affect these observations. Therefore, this information, while important, is not as critical as the patient’s pre-operative condition.

Choice D rationale

The condition of the patient’s abdomen (soft, bowel sounds absent) and the absence of bleeding on the dressing are expected observations in a patient who has undergone an exploratory laparotomy. These observations, while important, do not provide additional critical information that the PACU nurse should report.

A. Supervisor of the neurology unit. B. Nurse in charge of risk management. C. Nurse case manager. D. Adult nurse practitioner.

Correct Answer is C

Explanation

Choice A rationale

While the supervisor of the neurology unit may have expertise in neurology, they are not typically responsible for coordinating the progression of a patient’s care following a spinal cord injury.

Choice B rationale

The nurse in charge of risk management is typically responsible for identifying and evaluating risks in the healthcare setting. They are not typically involved in the direct management of a patient’s care.

Choice C rationale

The nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including spinal cord injuries. They work with the patient, family, and healthcare team to develop a comprehensive care plan.

Choice D rationale

While an adult nurse practitioner can provide a high level of care, they are not typically responsible for managing the progression of a patient’s care following a spinal cord injury.

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Which client statement or behavior is most likely associated with their current condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.Who should be contacted to manage the progression of the patient’s care?

Correct Answer is C

Explanation

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