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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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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:
The statement "Identify the client's current stage of grief" is the correct response. Understanding the client's current stage of grief is crucial for providing appropriate interventions. Grief can manifest in various stages, such as denial, anger, bargaining, depression, and acceptance. By identifying the stage, the nurse can tailor interventions to meet the client's specific needs and provide the most effective support.

Choice B reason:
The statement "Inform the client that feelings of anger are expected" is important but not the priority. While it is essential to validate the client's emotions and normalize their feelings, this intervention comes after understanding the client's current stage of grief. Knowing the stage helps in addressing the emotions more effectively.

Choice C reason:
The statement "Encourage the client to participate in physical activities" is beneficial but not the priority. Physical activities can help alleviate some symptoms of grief, such as depression and anxiety, by releasing endorphins and providing a distraction. However, this intervention should be based on the client's readiness and current stage of grief.

Choice D reason:
The statement "Discuss the use of a spiritual grief counselor with the client" is also important but not the priority. Spiritual counseling can provide significant support for clients experiencing complicated grief, especially if they have a strong spiritual or religious background. However, this intervention should be considered after assessing the client's current stage of grief to ensure it aligns with their needs and beliefs.

A. Repeat the dose in 15 minutes if the client is still anxious. B. Initiate fall precautions for the client. C. Instruct the client to expect ringing in the ears. D. Place the client in restraints for 1 hour.

Correct Answer is B

Explanation

Choice A reason:
The statement "Repeat the dose in 15 minutes if the client is still anxious" is not appropriate. Lorazepam is a benzodiazepine that can cause significant sedation and central nervous system depression. Repeating the dose too soon can increase the risk of severe sedation, respiratory depression, and other adverse effects.

Choice B reason:
The statement "Initiate fall precautions for the client" is the correct response. Lorazepam can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls, especially in older adults. Implementing fall precautions is essential to ensure the client's safety.

Choice C reason:
The statement "Instruct the client to expect ringing in the ears" is incorrect. Tinnitus (ringing in the ears) is not a common side effect of lorazepam. Common side effects include drowsiness, dizziness, and muscle weakness.

Choice D reason:
The statement "Place the client in restraints for 1 hour" is inappropriate. Restraints should only be used as a last resort when the client poses a danger to themselves or others and when less restrictive measures have failed. Lorazepam administration does not typically warrant the use of restraints.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?

Correct Answer is A

Explanation

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

A nurse is preparing to administer haloperidol 7 mg lIM to a client who is severely agitated. Available is haloperidol injection 5 mg/mL. How manymL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?

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 caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?

A nurse is caring for a client. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?