A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Use a cushion when sitting.

Perform range of motion exercises.

Document abdominal girth.

Weigh every morning.

Answer and Explanation

The Correct Answer is D

This is the best intervention for the PN to implement because it monitors the client's ﬂuid status and helps detect ﬂuid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.

A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.

B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.

C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of ﬂuid status.

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Correct Answer is A

Explanation

The correct answer is Choice A:

"Are you planning to obey the voices?.”. Choice A rationale:

The PN should ask the client if he plans to obey the voices because it helps assess the potential risk of harm to himself or others. If the client indicates an intention to follow the voices' commands to harm someone, it indicates a serious concern for safety and may require immediate intervention to protect the client and others.

Choice B rationale:

While asking if the client believes the voices are real is important for understanding the client's perception of the situation, it may not immediately address the risk of harm that the client or others might be facing.

Choice C rationale:

Asking if the client has taken any hallucinogens is relevant to explore possible substance- induced psychosis, but this question should be asked later in the assessment process. The priority is to assess immediate safety concerns related to the client's compliance with the voices' instructions.

Choice D rationale:

Inquiring about when the voices began is important, but it is not the most urgent question in this situation. Although the onset of the symptoms is relevant, addressing the potential for harmful actions should be prioritized.

A. Dim the lights in the room and close the door. B. Guide the client through slow, rhythmic breathing. C. Turn the television on to the client's favorite show. D. Obtain a prescription for a higher dose of pain medication.

Correct Answer is B

Explanation

This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non- pharmacological method of pain relief that can enhance the eﬀect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood ﬂow.

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A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The client tells the practical nurse (PN) that the voices are saying, "Kill, kill.”. Which question should the PN ask the client next?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Which action should the PN implement first?

Which finding should the practical nurse (PN) instruct the postpartum client to report to the charge nurse?

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At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? (Select all that apply.).

The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?