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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Excessive sweating is a common adverse effect of sertraline, and it is essential for the nurse to educate the client about this potential side effect to enhance medication adherence and manage expectations.
B. Dry cough is not typically associated with sertraline, and its inclusion in the education may confuse the client and undermine the credibility of the nurse's teaching.
C. Increased urinary frequency is not commonly reported with sertraline use; therefore, including it in the client education may lead to misinformation.
D. A metallic taste in the mouth is not a commonly reported adverse effect of sertraline and should not be included in the client education as it may cause unnecessary concern or confusion.
Correct Answer is B
Explanation
A. Warm skin temperature distal to pin site: Warmth in the extremity distal to the pin site is generally a positive sign and suggests adequate circulation.
B. A faint pedal pulse of the left leg suggests altered tissue perfusion distal to the traction site. This finding could indicate impaired blood flow to the foot, potentially due to the traction device compressing blood vessels or other circulatory issues.
C. Pain with movement of the left great toe: While pain with movement might indicate tissue injury, it's not necessarily indicative of altered tissue perfusion unless accompanied by other signs such as diminished pulse.
D. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered tissue perfusion.
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