A nurse is caring for an older adult client whose wife passed away a month ago with cardiac issues and is currently being treated for similar cardiac issues. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse?

"You are right, I cannot really understand. Perhaps you would like to tell me more about what you are feeling."

"It takes time to get over the loss of a loved one."

"Why don't you try something to take your mind off your troubles?"

"I might not share your exact situation, but I do know what people go through when they deal with a loss."

Answer and Explanation

The Correct Answer is A

Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.

Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.

Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.

Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.

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Correct Answer is A

Explanation

Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.

Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.

Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.

Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.

A. Prolonged bleeding B. Dry mucous membrane C. Peaked T-waves D. Polyuria

Correct Answer is C

Explanation

Choice A reason: Prolonged bleeding is not a direct indicator of hyperkalemia. It is more commonly associated with coagulation disorders or conditions affecting blood clotting.

Choice B reason: Dry mucous membranes are more indicative of dehydration rather than hyperkalemia. Dehydration can result from a variety of conditions but is not specific to high potassium levels.

Choice C reason: Peaked T-waves on an electrocardiogram (ECG) are a classic sign of hyperkalemia. Elevated potassium levels affect the cardiac conduction system, leading to characteristic changes in the ECG, such as tall, peaked T-waves, widened QRS complexes, and flattened P-waves.

Choice D reason: Polyuria (excessive urination) is not typically associated with hyperkalemia. It is more commonly seen in conditions like diabetes mellitus or diabetes insipidus.

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Naxlex Comprehensive Predictor Exams

The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

Correct Answer is A

Explanation

The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?

Correct Answer is C

Explanation

A client received atropine intraoperatively for symptomatic sinus bradycardia during a cardiac catheterization. In the immediate postoperative period, the nurse monitors the client for which effects of the medication?

A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?

The nurse in the medical ICU suspects that the client is experiencing a thyroid storm. Which clinical manifestations should the nurse anticipate?

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be the most useful to monitor?

The nurse is assessing a client's eyes and notes that when the client looks at a near object, the pupil constricts, but when the client looks at an object in the distance, the pupil dilates. The nurse should identify this finding as which condition?

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

The nurse realizes that which clients are at risk for intra-renal injury? (Select all that apply)