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A nurse is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Body System Findings

Neurologic:

Fatigue after being awake a few hours, feels “restless”. Difficulty concentrating on work and other activities. Difficulty falling asleep and wakes up “after a few hours". Worried about work and family needs.

Musculoskeletal:

Reports muscles feel tight and achy. Ambulates without assistance. Moves all four extremities independently.

Gastrointestinal:

Bowel sounds distant, present x four quadrants. Abdomen soft and nondistended, bladder slightly palpable.

Cardiovascular:

Apical 92/min and regular; peripheral pulses present bilaterally. Absence of lower extremity edema.

Respiratory:

Breath sounds present bilaterally. Occasional dry cough.

Fatigue after being awake a few hours, feels “restless”

Difficulty concentrating on work

Difficulty falling asleep

Worried about work and family needs

muscles feel tight and achy

Bowel sounds distant

Apical 92/min and regular

Occasional dry cough

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G","H"]

Neurologic:

Fatigue after being awake a few hours: Fatigue can be a symptom of various conditions, including anemia, depression, sleep disorders, and others. It’s important to investigate further to determine the cause.
Feels “restless”: Restlessness can be a symptom of mental health disorders like anxiety or physical conditions like restless leg syndrome. Further evaluation is needed.
Difficulty concentrating on work and other activities: This could be a symptom of stress, anxiety, depression, or other mental health conditions. It could also be related to the client’s reported fatigue.
Difficulty falling asleep and wakes up “after a few hours”: This could indicate a sleep disorder such as insomnia, which could also be contributing to the client’s fatigue and difficulty concentrating.
Worried about work and family needs: This could indicate stress or anxiety, which may need to be addressed with stress management strategies or counseling.

Musculoskeletal:

Reports muscles feel tight and achy: This could be due to overuse, stress, or a medical condition like fibromyalgia. Further investigation is needed.

Gastrointestinal:

Bowel sounds distant: This could indicate a slow-down in the digestive process and may require further investigation.

Cardiovascular:

Apical 92/min and regular: While this is within the normal range, it’s at the higher end. If the client isn’t physically active, it might be worth investigating further.

Respiratory:

Occasional dry cough: While this could be due to something benign like allergies, it could also be a symptom of a respiratory condition. If it persists, it should be investigated further.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:
This response acknowledges the partner's feelings and validates their emotional experience. It shows empathy and understanding, which are crucial in providing support during the grieving process. By recognizing the difficulty of the partner's emotions, the nurse helps create a safe space for the partner to express their feelings. This approach aligns with therapeutic communication techniques that emphasize active listening and emotional validation.

Choice B Reason:
Telling the partner that they shouldn't feel guilty and that they took excellent care of their partner, while well-intentioned, may come across as dismissive of their feelings. Guilt is a common emotion in grief, and it is important to allow the partner to express and process these feelings rather than dismissing them. The nurse should focus on validating the partner's emotions and providing a supportive environment.

Choice C Reason:
Sharing personal experiences, such as saying "I felt the same way when my partner died," can sometimes be helpful, but it may also shift the focus away from the partner's feelings. The primary goal is to support the partner and validate their emotions. While it can be comforting to know that others have had similar experiences, the nurse should be cautious about making the conversation about their own experiences.

Choice D Reason:
Suggesting that the partner see a grief counselor is a practical recommendation, but it may not be the most immediate or supportive response. The partner is expressing their emotions in the moment, and the nurse's priority should be to provide empathetic support. Once the partner feels heard and validated, the nurse can gently suggest additional resources like grief counseling.

A. Limit visitation from the client’s family. B. Reorient the client to person, place, and time frequently. C. Rotate nursing staff daily. D. Approach the client slowly. E. Maintain a low-stimulation environment.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Limiting visitation from the client’s family may not be beneficial as the presence of familiar people can often help reorient and calm the client. Family members can provide comfort and reassurance, which can be particularly helpful for a client experiencing delirium.
Choice B reason: Reorienting the client to person, place, and time frequently is a recommended intervention for patients with delirium. This can help reduce confusion and agitation in clients with delirium.
Choice C reason: Rotating nursing staff daily could potentially increase confusion for the client, as continuity of care and familiar faces can be beneficial in managing delirium. Therefore, this option is not recommended.
Choice D reason: Approaching the client slowly is a recommended intervention for patients with delirium. Given the client’s agitation and confusion, it’s important to approach them in a non-threatening manner to avoid escalating their distress.
Choice E reason: Maintaining a low-stimulation environment is a recommended intervention for patients with delirium. A calm and quiet environment can help reduce agitation and confusion in clients with delirium.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is visiting with the partner of a client who recently died. The partner expresses guilt that they did not do more for their partner. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415. Exhibits Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Correct Answer is ["B","D","E"]

Explanation

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

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A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?

A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?

A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client in an intensive care unit. The client develops delirium while recovering from surgery. To promote safety, which of the following actions should the nurse take?