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.

Answer and Explanation

The Correct Answer is []

Potential Condition The client is most likely experiencing b. Antisocial personality disorder. This is suggested by the client’s lack of remorse, impulsivity, deceitfulness, and aggressive behavior when denied something she wants.

Actions to Take To address this condition, the nurse should:

a. Assess history of criminal behavior: This can provide insight into the severity and pattern of the client’s antisocial behavior.
e. Establish clear and realistic boundaries regarding behavior: This can help manage the client’s impulsivity and aggressive behavior.

Parameters to Monitor To assess the client’s progress, the nurse should monitor:

c. Aggressive and violent behavior: Any reduction in these behaviors can indicate improvement.
e. Deceitfulness: A decrease in deceitful behavior can also signal progress.

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Correct Answer is C

Explanation

Choice A Reason:
Sodium levels within the range of 136 to 145 mEq/L are considered normal. A sodium level of 140 mEq/L falls within this range and does not indicate any immediate concern. Sodium is an essential electrolyte that helps maintain fluid balance, nerve function, and muscle function. Since the sodium level is normal, there is no need to notify the provider about this result.

Choice B Reason:
A WBC (white blood cell) count of 6,000/mm³ is within the normal range of 5,000 to 10,000/mm³. White blood cells are crucial for the immune system to fight infections. Since the WBC count is normal, it does not warrant notifying the provider. Monitoring WBC counts is important in clients taking antipsychotic medications like risperidone, but this result is within the expected range.

Choice C Reason:
A blood glucose level of 256 mg/dL is significantly higher than the normal range of 74 to 106 mg/dL. Elevated blood glucose levels can indicate hyperglycemia, which is a common side effect of antipsychotic medications like risperidone. Hyperglycemia can lead to serious complications if not managed properly, including diabetic ketoacidosis and long-term cardiovascular issues. Therefore, it is crucial to notify the provider about this elevated blood glucose level to adjust the treatment plan and prevent further complications.

Choice D Reason:
Platelet counts within the range of 150,000 to 400,000/mm³ are considered normal. A platelet count of 250,000/mm³ falls within this range and does not indicate any immediate concern. Platelets are essential for blood clotting and wound healing. Since the platelet count is normal, there is no need to notify the provider about this result.

A. Recommend that the client participate in more solitary activities. B. Explain to the client that the duration of grief is highly variable and can last for years. C. Encourage the client to avoid discussing the events surrounding the sibling's death. D. Caution the client against feeling angry at the sibling.

Correct Answer is B

Explanation

Choice A reason:
The statement "Recommend that the client participate in more solitary activities" is not advisable. Solitary activities can sometimes exacerbate feelings of isolation and depression. Instead, engaging in social activities and seeking support from friends, family, or support groups can be more beneficial for someone experiencing grief.

Choice B reason:
The statement "Explain to the client that the duration of grief is highly variable and can last for years" is the correct response. Grief is a highly individual process, and there is no set timeline for how long it should last. Normalizing the client's experience and validating their feelings can help them understand that their prolonged grief is not unusual.

Choice C reason:
The statement "Encourage the client to avoid discussing the events surrounding the sibling's death" is not appropriate. Discussing the events and expressing emotions related to the loss are important aspects of the grieving process. Avoiding these discussions can hinder the client's ability to process their grief.

Choice D reason:
The statement "Caution the client against feeling angry at the sibling" is not advisable. Anger is a common and natural part of the grieving process. It is important to validate the client's feelings and help them understand that it is okay to feel a range of emotions, including anger.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

A nurse is caring for a client who has narcissistic personality disorder. Which of the following treatments should the nurse recommend?

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 is preparing to teach a client who has moderate anxiety about what to expect after their upcoming cardiac catheterization. Which of the following actions should the nurse plan to take?