A nurse is caring for a client in the outpatient health clinic.

Exhibits

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Instruct client to avoid foods that have been fermented or aged.

Encourage client to sleep until later in the morning.

Advise client to notify provider if pregnant.

Encourage high-calorie finger foods.

Advise client to rise slowly from sitting position.

Encourage naps during the day when client is tired.

Encourage a regular sleep-wake schedule.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Rationale:

Instruct client to avoid foods that have been fermented or aged: This dietary restriction applies to monoamine oxidase inhibitors (MAOIs), not trazodone, which is a serotonin antagonist and reuptake inhibitor (SARI).
Encourage client to sleep until later in the morning: Oversleeping can disrupt circadian rhythms and worsen fatigue. A consistent, balanced sleep schedule is more therapeutic.
Advise client to notify provider if pregnant: Trazodone is a category C medication and should only be used in pregnancy if the benefits outweigh the risks. The provider must be informed if the client is or may become pregnant.
Encourage high-calorie finger foods: The client has experienced weight loss and decreased appetite. Nutrient-dense, easy-to-eat foods can support caloric intake without requiring full meals.
Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension. Educating the client to change positions slowly helps prevent dizziness and potential falls.
Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep and may reduce trazodone’s effectiveness in establishing a healthy sleep pattern.
Encourage a regular sleep-wake schedule: Trazodone is often prescribed for sleep difficulties. A consistent routine supports sleep hygiene and enhances the medication’s effectiveness.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Rationale:

A. Explain to the client they can change their mind at any time: Clients have the right to make or revoke decisions about resuscitation at any time. Informing the client of this autonomy supports informed consent and respects their evolving preferences and values regarding end-of-life care.

B. Obtain consent from the family for the change to the plan of care: The decision for a Do Not Resuscitate (DNR) order is made by the client, not the family, if the client is competent. Family involvement is supportive but does not override the client’s autonomy in this matter.

C. Discharge the client to hospice care: While hospice may be appropriate for end-stage disease, requesting a DNR does not automatically necessitate discharge. Clients can remain in the current care setting with appropriate adjustments to their goals of care.

D. Place a sign with "Do Not Resuscitate" outside the client's room: Displaying such signs can violate privacy and confidentiality. Instead, the DNR order should be documented clearly in the medical record and care plan, accessible to the healthcare team.

A. "You should avoid vaginal spermicides while breastfeeding." B. "The lactation amenorrhea method is effective for your first year postpartum." C. "Place the transdermal birth control patch on your upper outer arm." D. "You can continue to use the diaphragm you used before your pregnancy."

Correct Answer is C

Explanation

Rationale:

A. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides are generally considered safe during breastfeeding. They do not contain hormones and do not affect milk production, so avoidance is not typically necessary unless the client has specific contraindications.

B. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective during the first 6 months postpartum, provided the mother is exclusively breastfeeding and menstruation has not resumed. Beyond that period, the risk of ovulation increases and it becomes unreliable.

C. "Place the transdermal birth control patch on your upper outer arm.": The patch can be applied to several sites, including the upper outer arm, abdomen, buttock, or upper torso. This is an appropriate instruction and part of standard patient teaching for transdermal contraceptive use.

D. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm often requires refitting postpartum due to changes in vaginal tone and cervix position. Using the same diaphragm without evaluation could reduce effectiveness and increase risk of unintended pregnancy.

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A nurse is caring for a client in the outpatient health clinic. Exhibits For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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A nurse is caring for a client in the outpatient health clinic.

Exhibits

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.