A client age 56 years is experiencing withdrawal from alcohol and is placing themselves at risk for falls by repeatedly attempting to scale the bedrails. Benzodiazepines have failed to alleviate the client's agitation, and the nurse is considering obtaining an order for physical restraints to ensure client safety. The nurse should recognize that this measure may constitute:

Harm.

Paternalism.

Deception.

Advocacy.

Answer and Explanation

The Correct Answer is B

A. While physical restraints may potentially cause harm, the intention in this case is to ensure safety, so it isn't directly categorized as harm.
B. Paternalism involves making decisions for the patient without their consent, believing it's for their own good, which is what the nurse is considering by using restraints for safety.
C. Deception is not involved in this situation, as the nurse is not misrepresenting the circumstances.
D. Advocacy would involve advocating for the patient's autonomy, which may not align with using restraints without the patient's consent.

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Correct Answer is C

Explanation

A. Physiologic indicators can be helpful in pain assessment, but they are not directly linked to pain intensity scales, which are focused on subjective reports.
B. Pain intensity scales still involve a subjective component, as they rely on the patient’s report of their pain, even if the scale itself is structured.
C. A specific pain intensity scale provides consistency in how pain is assessed, allowing for more reliable tracking and management of pain across different shifts and caregivers.
D. While pain scales include subjective reports, they do not focus solely on objective data. The goal is to measure the patient's perception of pain.

A. Excessive fluid losses may lead to dehydration and hypovolemic shock. B. Hemodilution may cause deleterious hypernatremia. C. Fluid volume excess can lead to right-sided heart failure. D. Fluid retention occurs with tachypnea.

Correct Answer is C

Explanation

A. Excessive fluid losses may lead to dehydration, but this is not typically a primary concern for patients with pulmonary alterations unless there is significant vomiting, diarrhea, or blood loss.
B. Hemodilution is not a common concern in patients with pulmonary alterations. Hypernatremia typically occurs with fluid loss or inadequate fluid intake, but it is not a direct concern related to pulmonary issues.
C. Fluid volume excess can lead to right-sided heart failure in patients with pulmonary alterations. If fluid accumulates, it can worsen pulmonary symptoms and increase the workload on the heart, potentially leading to right-sided heart failure.
D. Fluid retention with tachypnea is not typically a direct cause of fluid retention. While tachypnea is associated with respiratory distress, fluid retention is more closely linked to heart failure or kidney dysfunction.

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Naxlex Comprehensive Predictor Exams

Why use a specific pain intensity scale in the critical care unit?

Correct Answer is C

Explanation

You are explaining the importance of strict intake and output for patients with pulmonary alterations. What is the rationale for careful intake and output for patients with pulmonary alterations?

Correct Answer is C

Explanation

A nurse demonstrates the professional value known as altruism when caring for clients in a long-term care facility. What nursing action demonstrates this behavior?

The nurse and the other members of the team are caring for a client in the ED who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. Which medication should the nurse be prepared to administer?

A patient has a new order for intermittent nasogastric feedings every 4 hours. The nasogastric tube is placed by the nurse. What is the most accurate method for confirming the placement of the tube before initiating the feeding?

Which ethical principle is most important when soliciting informed consent from a patient?

A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse's first priority?

Which combinations of drugs have been found to be effective in managing the pain associated with musculoskeletal and soft tissue inflammation?

A client is complaining of severe chest pain became unresponsive and the cardiac monitor shows the heart rhythm below. What will be the most appropriate actiondropdown. What is the heart rhythmdropdown

A nurse is paying particular attention to the spiritual needs of a client today. The nurse identifies that spiritual beliefs can have a positive effect on general health of a client in which ways? Select all that apply.