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","B","E"]

Explanation

Choice A rationale

Removing resuscitation equipment from the room is a standard practice before allowing family members to view the body after an unsuccessful resuscitation. This helps to create a more peaceful and less distressing environment for the family. It also respects the dignity of the deceased and allows the family to focus on their loved one, rather than the medical interventions that were attempted.

Choice B rationale

Placing a small pillow under the head is a common practice in preparing the body for viewing by the family. This helps to position the body in a natural and peaceful manner, which can be comforting for the family. It also respects the dignity of the deceased.

Choice E rationale

Gently closing the eyes is another common practice in preparing the body for viewing by the family. This helps to give the appearance of peaceful rest, which can be comforting for the family. It also respects the dignity of the deceased.

Choice C rationale

Taking out dentures and placing them in a labeled cup is not a standard practice in preparing the body for viewing by the family. Dentures, if present, are usually left in place to maintain the natural appearance of the face.

Choice D rationale

Applying a body shroud is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.

A. Apply ice, then a warm compress to the IV site. B. Check the medical record for the date of IV insertion. C. Redress the IV site while checking for redness. D. Discontinue the current IV site and insert a new one.

Correct Answer is D

Explanation

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.

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

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Naxlex Comprehensive Predictor Exams

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

Correct Answer is D

Explanation

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