A nurse is caring for a client in an emergency department.

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 []

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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Correct Answer is C

Explanation

A. Prealbumin levels are often used as a marker of nutritional status and can indicate protein deficiency. A low prealbumin level may suggest malnutrition or inadequate protein intake. However, the prealbumin level of 25 mg/dL is within the normal range (normal range typically 15-35 mg/dL), so it does not require immediate reporting to the provider.
B. The client's temperature of 37.6°C (99.7°F) is slightly elevated but is not indicative of a fever (typically defined as ≥38°C or 100.4°F). This finding may suggest a mild increase in body temperature, which could be related to various factors such as dehydration, infection, or environmental factors. Since it's only slightly elevated and within a

borderline range, it may not require immediate reporting unless other concerning symptoms are present.
C. Urine specific gravity measures the concentration of solutes in the urine and can indicate hydration status. A specific gravity of 1.035 is considered high and may suggest concentrated urine, which could be a sign of dehydration or renal dysfunction. Therefore, this finding should be reported to the provider for further evaluation.
D. Hypoactive bowel sounds indicate decreased or absent bowel motility and can be a sign of gastrointestinal dysfunction, such as ileus or obstruction. While it's important to monitor bowel sounds and report any significant changes to the provider, hypoactive bowel sounds alone may not always require immediate reporting unless other concerning symptoms are present.

A. Palms of the hands B. Sclera C. Shoulders D. Face

Correct Answer is B

Explanation

A. The palms of the hands are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
B. Jaundice is characterized by the yellowing of the skin and eyes due to high levels of bilirubin in the blood. In individuals with dark skin, this yellowing may not be as apparent on the skin itself, making the sclera a more accurate site for assessment.
C. The shoulders are less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.
D. The face is less reliable for detecting jaundice in dark-skinned individuals because the yellow tint may not be as visible against the darker pigmentation.

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Naxlex Comprehensive Predictor Exams

Exhibits A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is C

Explanation

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice?

Correct Answer is B

Explanation

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