A nurse is preparing to discharge an older adult patient who had a mastectomy several months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "my body is so different now." Which of the following is an appropriate response by the nurse?

"It is still too soon to expect to feel normal. Give it a few more years."

"Really, you look just fine to me. There's no need to feel undesirable."

"Consider an afternoon at the spa. A facial will make you feel more attractive."

"I'm interested in finding out more about how your body feels to you."

Answer and Explanation

The Correct Answer is D

Choice A reason: Telling the client it is too soon to expect to feel normal and to give it a few more years dismisses her feelings and provides an unrealistic timeline. It is not supportive or empathetic.

Choice B reason: Saying "Really, you look just fine to me. There's no need to feel undesirable" invalidates the client's feelings and does not address her concerns about her body image and sexual desire.

Choice C reason: Suggesting an afternoon at the spa and a facial to make her feel more attractive trivializes the client's emotional and physical experience post-surgery. It does not provide meaningful support or address the underlying issues.

Choice D reason: Expressing interest in how the client's body feels to her validates her feelings and opens up a dialogue for her to share her concerns. This approach is empathetic and allows the nurse to provide better support and address any issues the client might have.

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Correct Answer is A

Explanation

Choice A reason: Defibrillation is the appropriate intervention for pulseless ventricular tachycardia (VT). It delivers an electrical shock to the heart to restore a normal rhythm. Immediate defibrillation is crucial for survival as it can terminate the arrhythmia and allow the heart to re-establish an effective rhythm.

Choice B reason: Vagal maneuvers, such as the Valsalva maneuver, are used to terminate supraventricular tachycardias but are ineffective for pulseless VT. These maneuvers stimulate the vagus nerve to slow the heart rate but do not provide the necessary intervention for life-threatening arrhythmias like pulseless VT.

Choice C reason: Radiofrequency catheter ablation is a procedure used to treat recurrent arrhythmias by destroying abnormal electrical pathways in the heart. It is not an emergency intervention for pulseless VT. Defibrillation is needed to address the immediate, life-threatening situation.

Choice D reason: Administration of atropine is not indicated for pulseless VT. Atropine is used to treat bradycardia by increasing heart rate, but it does not address the underlying cause of VT. Defibrillation is the correct immediate intervention for pulseless VT.

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

A nurse is caring for a client who is found unresponsive and pulseless in their room. An ECG confirms the client is in pulseless ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

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 is brought into the emergency room with sudden severe complaints of eye pain, blurred and decreased visual acuity, and extreme pressure in their eyes. The nurse would most likely suspect the client to have:

The nurse is caring for a child who was recently diagnosed with moderate persistent asthma. Which common asthma triggers should the nurse teach the client to avoid?

There are several factors that may cause a patient to present with sinus bradycardia. What are some causes of sinus bradycardia? (Select all that apply)

The nurse identifies the client exhibiting supraventricular tachycardia and calls the provider. Several orders are given. For which of the following orders would the nurse request further clarification? (Select all that apply)

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which statement by the client indicates a need for clarification?

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 giving a client with chronic obstructive pulmonary disease (COPD) information related to positions used to breathe more easily. The nurse teaches the client to assume which position?