A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Vomiting

Urticaria

Low back pain

Pulmonary congestion

Answer and Explanation

The Correct Answer is C

Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.

Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.

Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.

Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.

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Correct Answer is B

Explanation

Choice A reason: While providing information on stress reduction is helpful, it is not the immediate priority.

Choice B reason: Assisting the client to identify triggers is a priority as it directly addresses the cause of the OCD behaviors.

Choice C reason: Speaking to the client in a calm manner is supportive but does not address the underlying OCD behaviors.

Choice D reason: Identifying anxiety levels can be part of the intervention, but it is not as specific as identifying triggers for the OCD behaviors.

A. Auditory hallucinations B. Free-floating anxiety C. Flashbacks D. Delusions of grandeur

Correct Answer is C

Explanation

Choice A reason: Auditory hallucinations involve hearing voices or sounds that are not present, which does not match Audrey's experience of visual perceptions.

Choice B reason: Free-floating anxiety is a general feeling of unease that is not tied to a specific situation, whereas Audrey's anxiety is triggered by a specific scenario reminiscent of past trauma.

Choice C reason: Flashbacks are vivid, often distressing, memories of past traumatic events that feel as though they are happening in the present. Audrey's experience is indicative of flashbacks related to her military service.

Choice D reason: Delusions of grandeur involve beliefs of inflated worth, power, or identity, which is not described in Audrey's situation.

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A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?

Correct Answer is B

Explanation

Audrey is a veteran who served in Afghanistan. She finds it very difficult to drive through a parking ramp because she perceives that "There are people hiding behind the pillars! They have guns! Be careful." Audrey is most likely experiencing which of the following?

Correct Answer is C

Explanation

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