A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours.

Complete the diagram by dragging from the choices area to specify which 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.

Answer and Explanation

The Correct Answer is []

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Correct Answer is D

Explanation

Choice A rationale
Demonstrating signs of early dementia involves more than just walking aimlessly and staring blankly. It includes memory loss, difficulty with complex tasks, and changes in personality or behavior.
Choice B rationale
Appearing confused and depressed is a subjective interpretation and does not accurately describe the observed behavior. Documentation should be objective and specific.
Choice C rationale
Ambulatory and disoriented to place is a partial description but does not capture the full extent of the observed behavior, including the blank expression.
Choice D rationale
Wandering behavior with flat affect accurately describes the observed behavior. It is specific and objective, noting both the physical action (wandering) and the emotional state (flat affect)2.

A. White blood cell count (WBC). B. Blood urea nitrogen (BUN). C. Hematocrit. D. Glucose.

Correct Answer is C

Explanation

Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.

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Naxlex Comprehensive Predictor Exams

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression.How should the nurse enter documentation of this finding in the client’s electronic medical record (EMR)?

Correct Answer is D

Explanation

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is C

Explanation

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

When evaluating a client’s rectal bleeding, which findings should the nurse document?