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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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Correct Answer is C

Explanation

Choice A reason:
The statement "Promote decision making about care" is not appropriate for a client experiencing delirium. Delirium can cause confusion, disorientation, and impaired decision-making abilities. Encouraging the client to make decisions about their care may increase their anxiety and confusion.

Choice B reason:
The statement "Discourage visits from significant others" is not advisable. Visits from familiar people can provide comfort and reassurance to a client experiencing delirium. Isolation can exacerbate feelings of confusion and distress.

Choice C reason:
The statement "Provide environmental cues" is the correct response. Environmental cues, such as clocks, calendars, and familiar objects, can help orient the client and reduce confusion. Maintaining a consistent routine and minimizing environmental changes can also promote safety and comfort.

Choice D reason:
The statement "Apply physical restraints" is not recommended as a first-line intervention. Physical restraints can increase agitation and the risk of injury. They should only be used as a last resort when the client poses an immediate danger to themselves or others and when less restrictive measures have failed.

A. Naltrexone B. Donepezil C. Varenicline D. Disulfiram

Correct Answer is C

Explanation

Choice A Reason:
Naltrexone is primarily used to treat alcohol and opioid dependence. It works by blocking the euphoric and sedative effects of these substances, reducing the desire to use them. While naltrexone has been studied for smoking cessation, it is not commonly prescribed for this purpose. Its primary use remains in the management of alcohol and opioid addiction.

Choice B Reason:
Donepezil is a medication used to treat symptoms of Alzheimer's disease. It works by increasing the levels of acetylcholine in the brain, which helps improve cognitive function. Donepezil is not indicated for smoking cessation and does not have any known effects on nicotine addiction or withdrawal symptoms.

Choice C Reason:
Varenicline, also known by the brand name Chantix, is specifically designed to help people quit smoking. It works by binding to nicotine receptors in the brain, reducing the pleasurable effects of smoking and alleviating withdrawal symptoms. Varenicline has been shown to be highly effective in helping individuals quit smoking and is a common prescription for this purpose.

Choice D Reason:
Disulfiram is a medication used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking alcohol). It works by inhibiting the enzyme acetaldehyde dehydrogenase, leading to unpleasant effects when alcohol is consumed. Disulfiram is not used for smoking cessation and does not affect nicotine addiction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a client who is seeking help to quit smoking. Which of the following prescriptions should the nurse expect the provider to prescribe?

Correct Answer is C

Explanation

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A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

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A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take?