A nurse is caring for a client in an emergency department.
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
The Correct Answer is []
Based on the provided nurses' notes, the client exhibits symptoms that may suggest a brief psychotic disorder, characterized by delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The client's history of similar episodes and family history could support this diagnosis. To assess the client's progress, the nurse should monitor the client's ability to care for themselves and assess any suicide risk due to the client's recent stressors and emotional state. Actions that could be beneficial include reducing external stimuli to prevent sensory overload and engaging with the client several times each day to establish trust, which can help alleviate anxiety and foster a therapeutic environment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Flattening of the artificial airway cuff. This would indicate a problem, such as a leak, not a successful outcome of suctioning.
B. This indicates that the airway resistance has been reduced following suctioning, which suggests that the suctioning was effective in clearing the airway obstruction caused by secretions.
C. Thinning of mucous secretions is not a direct indication of effective suctioning; while thinner secretions may be easier to remove, the goal of suctioning is to clear the airways rather than alter the consistency of the secretions.
D. The presence of a productive cough is not relevant in the context of a patient who is intubated and mechanically ventilated, as they would be unable to cough effectively due to the endotracheal tube.
Correct Answer is D
Explanation
A. While completing an incident report is important for addressing the medication error and implementing corrective actions, the immediate priority is to assess the client's condition for signs of bleeding, which could be life-threatening.
B. Monitoring aPTT levels is important to assess the client's response to heparin therapy, but it does not address the immediate risk of bleeding from the overdose.
C. Notifying the risk manager is essential for reporting the medication error and implementing strategies to prevent future occurrences, but the nurse's first action should be to assess the client's condition for any indications of bleeding.
D. Administering a high dose of heparin increases the risk of bleeding, so the nurse should first assess the client for any signs or symptoms of bleeding, such as unexplained bruising, hematuria, or hypotension, to ensure timely intervention and prevent complication.
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