Which entry made my nurse most accurately documents a client's mood?

The client has a pleasant affect

The client appears happy with an elevated mood

The client self-isolated today

The client rate their mood 4 out of 10

Answer and Explanation

The Correct Answer is D

A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.

B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.

C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.

D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.

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Correct Answer is A

Explanation

A. Chest physiotherapy (CPT) every 4 hours while awake. CPT is used to mobilize secretions but may be too aggressive for a patient with infiltrates and respiratory distress, as it can increase fatigue and worsen respiratory status.

B. Oxygen therapy via nasal cannula at 3 to 4 L/min. Low-flow oxygen therapy is often used in COPD to prevent hypoxemia while avoiding CO₂ retention.

C. Add humidification to the oxygen source. Humidified oxygen helps prevent airway dryness and improves secretion clearance, which is beneficial for COPD patients.

D. Raise the head of the patient's bed. Elevating the head of the bed promotes lung expansion and improves oxygenation, making this an appropriate intervention.

A. Chronic confusion r/t ECT treatment B. Activity intolerance r/t weakness C. Impaired social interaction r/t confusion D. Risk for injury r/t altered mental status

Correct Answer is D

Explanation

A. Chronic confusion r/t ECT treatment. Memory impairment may occur but is not the immediate priority.

B. Activity intolerance r/t weakness. Weakness can occur but is not the most urgent concern post-ECT.

C. Impaired social interaction r/t confusion. Social interaction is a lower priority compared to physical safety.

D. Risk for injury r/t altered mental status. Post-ECT, clients may be confused or disoriented, increasing their risk of falls or injury. Ensuring safety is the top priority.

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Which entry made my nurse most accurately documents a client's mood?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which of the following nursing diagnosis take priority immediately after electroconvulsive therapy (ECT)

Correct Answer is D

Explanation

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