A nurse is caring for a client who has a mental disorder. Which of the following statements by the client suggests the inability to process new information?

"I need to catch the bird that is flying in my room."

"I feel like someone is watching me."

"I have a difficult time remembering things."

"I am sad no matter how well things are going."

Answer and Explanation

The Correct Answer is C

A.   This statement suggests a delusion or hallucination, which are common symptoms of some mental disorders, but it does not specifically suggest an inability to process new information.
B.   This statement suggests paranoia, which is a common symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
C.   This statement suggests difficulty with memory, which is a cognitive function that is related to the ability to process new information.
D.   This statement suggests a persistent negative mood, which is a symptom of some mental disorders, but it does not specifically suggest an inability to process new information.

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Correct Answer is ["A","B","C","E"]

Explanation

A. A weakened gag reflex is a common complication of cervical spinal cord injuries and can lead to difficulty swallowing and increased risk of aspiration.
B. Hyperthermia can occur due to autonomic dysreflexia, a common complication of cervical spinal cord injuries.
C. Absence of bowel sounds can indicate a paralytic ileus, a common complication of cervical spinal cord injuries.
D. Polyuria is not a common complication of cervical spinal cord injuries. It may occur due to other factors, such as diabetes insipidus, but it is not directly related to the injury itself.
E. Hypotension can occur due to autonomic dysreflexia, a common complication of cervical spinal cord injuries.

A. Reinforce the importance of daily weights. B. Call the health care provider for further instructions. C. Document the findings and continue with the visit. D. Ensure the client has been taking their prescribed diuretic.

Correct Answer is D

Explanation

A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.

B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.

C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.

D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.

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A nurse is caring for a client who has a mental disorder. Which of the following statements by the client suggests the inability to process new information?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Correct Answer is D

Explanation

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