Video Library
Rn Concept Based Assessment Proctored Exam Level 4 With Ngn
Total Questions : 136
Showing 10 questions, Sign in for more0800:
Client is brought to the emergency department by their partner. who reports changes in the client's alertness and mood over the last few days. The client appears unkempt and lethargic.
1200:
The client is transferred to a medical intensive care unit (ICU) for further monitoring. The client is awake and oriented to person and place. Client is lethargic.
- Liver failure
- Alcoholism
1000:
- Electroencephalography shows generalized slowing
1100:
- Lactulose 20 g PO daily
- Hand tremors
- Lethargic but follows simple commands
- 1+pitting edema to both ankles
A nurse is caring for a client admitted to an emergency department (ED) for changes in mental status.
Complete the following sentence by using the list of options.
The client is at highest risk for developing
Explanation
Rationale for correct choices:
• Hepatic encephalopathy: The client has a history of liver failure and alcoholism and presents with altered mental status, lethargy, generalized slowing on electroencephalography (EEG), and hand tremors. These findings are classic manifestations of hepatic encephalopathy, a serious complication of liver failure caused by the accumulation of neurotoxins such as ammonia. The prescription for lactulose further supports this diagnosis, as lactulose is the first-line treatment to reduce serum ammonia levels.
• Neurologic assessment: The client's neurologic findings—including changes in mental status, lethargy, decreased level of consciousness, hand tremors (asterixis may also be present), and generalized slowing on EEG—provide evidence of hepatic encephalopathy. Ongoing neurologic assessment is essential to detect worsening encephalopathy, which can progress to seizures, coma, and death if untreated.
Rationale for incorrect choices:
• Impaired skin integrity: Although the client has 1+ pitting edema, edema alone does not indicate impaired skin integrity. There is no evidence of skin breakdown, pressure injuries, or impaired tissue perfusion in the assessment.
• Malnutrition: Clients with alcoholism and liver disease are at risk for malnutrition, but no findings such as significant weight loss, muscle wasting, vitamin deficiencies, or inadequate nutritional intake are provided. The client's acute priority is neurologic deterioration.
• Edema: Bilateral ankle edema is consistent with fluid retention and hypoalbuminemia associated with liver disease but is not evidence of hepatic encephalopathy. It also does not by itself indicate impaired skin integrity.
• Decreased protein reserves: Liver disease can reduce protein synthesis, including albumin production, but decreased protein reserves are not the assessment finding that best supports the diagnosis of hepatic encephalopathy. The client's neurologic abnormalities are the key evidence supporting this condition.
0900:
Client is a 75-year-old female being treated for sepsis from a urinary tract infection; client lethargic, receiving intravenous fluids and antibiotics as prescribed.
0950:
Client had a 250 mL frank blood emesis; blood specimens sent as prescribed.
0900:
- Neurologic: lethargic
- Integumentary: extremities cool and clammy
- Cardiovascular: apical 104/min and regular, capillary refill 3 seconds
- Hip replacement 5 years ago
- Hypertension x 10 years
- Treated for acute alcohol intoxication at age 50
0950:
- Neurologic: restless, confused
- Integumentary: small petechiae over lower arms; bleeding from previous intravenous site
- Respiratory: breath sounds high pitched over bilateral lung lobes
- Cardiovascular: apical 114/min and regular, capillary refill 3 seconds
- Gastrointestinal: abdomen firm and distended
0900:
- Temperature 37.4° C (99.3° F)
- Heart rate 104/min
- Respiratory rate 22/min
- Blood pressure 132/78 mm Hg
- Oxygen saturation 95% on 2 L of oxygen via nasal cannula
0950:
- Temperature 36.6° C (97.9" F)
- Heart rate 114/min
- Respiratory rate 24/min
- Blood pressure 105/64 mm Hg
- Oxygen saturation 92% on 2 L of oxygen via nasal cannula
1000:
- Platelets 100,000/mm3 (150,000 to 400,000/mm3)
- Prothrombin time 20 seconds (11 to 12.5 seconds)
- Activated partial thromboplastin time 47 seconds (30 to 40 seconds)
A nurse is caring for a client experiencing an acute change in symptoms.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for Correct Choices
• Disseminated intravascular coagulation (DIC): The client has sepsis, the most common precipitating factor for DIC. Findings supporting DIC include frank blood emesis, petechiae, bleeding from the IV site, hypotension, tachycardia, confusion, thrombocytopenia (platelets 100,000/mm³), prolonged PT (20 seconds), and prolonged aPTT (47 seconds). These findings indicate widespread activation of the clotting cascade with consumption of platelets and clotting factors, resulting in excessive bleeding.
• Administer heparin as prescribed: Although DIC is associated with bleeding, heparin may be prescribed in selected cases of DIC to interrupt ongoing coagulation, prevent further microvascular thrombosis, and reduce consumption of clotting factors. The nurse should administer it only when prescribed and closely monitor for bleeding.
• Reposition in bed carefully: Clients with DIC are at high risk for bleeding due to depletion of clotting factors and platelets. Gentle handling and careful repositioning help minimize tissue trauma, bruising, and hemorrhage.
• Fibrinogen level: Fibrinogen is consumed during DIC and is typically decreased. Monitoring fibrinogen levels helps evaluate the severity of the disorder and the effectiveness of treatment.
• Bleeding from other sites: Continuous assessment for bleeding from IV sites, mucous membranes, urine, stool, surgical wounds, and puncture sites is essential because hemorrhage is a major complication of DIC.
Rationale for Incorrect Choices
• Peptic ulcer: Although the client has hematemesis, peptic ulcer disease does not explain the petechiae, bleeding from the IV site, thrombocytopenia, prolonged coagulation studies, and recent sepsis.
• Thrombocytopenic purpura: This condition causes thrombocytopenia and bleeding but does not typically present with prolonged PT and aPTT or occur secondary to sepsis with widespread activation of coagulation.
• Liver cirrhosis: A history of alcohol intoxication alone does not indicate cirrhosis. The acute onset of bleeding abnormalities in the setting of sepsis is more consistent with DIC.
• Prepare the client for a bone marrow aspirate: Bone marrow aspiration is used to evaluate hematologic disorders and is not indicated for diagnosing or treating DIC.
• Obtain a blood specimen for H. pylori: Testing for H. pylori is appropriate when evaluating peptic ulcer disease, not DIC.
• Provide teaching to the client about paracentesis: Paracentesis is performed to remove ascitic fluid in clients with significant ascites and is unrelated to the management of DIC.
• Ammonia level: Ammonia is monitored in clients with hepatic encephalopathy due to liver failure, not DIC.
• Splenomegaly: Splenic enlargement is associated with certain hematologic or liver disorders but is not a parameter used to assess progression of DIC.
• Epigastric pain: Epigastric pain is more consistent with peptic ulcer disease and is not a hallmark feature used to monitor disseminated intravascular coagulation
A nurse is providing teaching to the guardians of a child who has cystic fibrosis. Which of the following instructions should the nurse include?
A nurse is working with an interdisciplinary quality improvement team to analyze a sentinel event in an intensive care unit. Which of the following tools should the nurse use to identify the source of the sentinel event?
A nurse is teaching a client about manifestations of rejection following a liver transplant. Which of the following findings should the nurse include in the teaching?
A nurse is admitting a client who had a stroke. To ensure coordination of care across the disciplines, which of the following actions should the nurse take?
A nurse manager is providing information to a group of nurses about Medicare. Which of the following information should the nurse manager include?
A nurse is developing a plan of care for a client who has a head injury. Which of the following interventions should the nurse include in the plan to prevent the client from experiencing an increase in intracranial pressure? (Select all that apply.)
A charge nurse is serving as the change agent to implement a policy change on his unit. According to Lewin's Change Theory, in which order should the charge nurse take the following actions during the movement phase? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Explanation
Brief Introduction:
Lewin's Change Theory consists of unfreezing, movement, and refreezing phases that facilitate organizational change through structured planning, implementation, and reinforcement. The movement phase emphasizes planned action, staff engagement, and continuous support to achieve sustainable practice improvement.
Rationale:
A. Setting goals and objectives establishes the direction of the planned change. Clear outcomes guide implementation and provide measurable performance expectations. Staff understand the intended practice improvements. This is the first planning step during the movement phase.
B. Setting target dates establishes realistic timelines for implementing each component of the change. Defined deadlines improve accountability and monitor progress. Scheduling facilitates coordinated implementation activities. This follows establishment of objectives.
C. Implementing the policy change places the planned intervention into practice after goals and timelines have been established. Staff begin using the new procedures in clinical care. This represents the active implementation stage of the movement phase.
D. Remaining available for staff support promotes successful adaptation to the new policy. Guidance, feedback, and problem-solving reduce resistance and increase staff confidence. Ongoing assistance strengthens compliance. Continuous support follows implementation.
E. Evaluating the policy change determines whether established goals were achieved using measurable outcomes. Findings identify successes and areas requiring modification. Evaluation provides evidence for sustaining improvements. This is the final assessment step before long-term stabilization of the change.
A charge nurse is supervising a newly licensed nurse who is changing an ostomy appliance for a client. The charge nurse should intervene for which of the following actions by the newly licensed nurse?
Sign Up or Login to view all the 136 Questions on this Exam
Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
