A nurse is reviewing the day 5 vital signs and nurses' notes.

Exhibits

A nurse is evaluating the client's response to treatment.

Select the 4 findings that indicate the client is progressing with their plan of care.

Appetite

Movement through the stages of grief

Cognition

Participation in group therapy

Client resolves to limit alcohol consumption

Answer and Explanation

Correct Answer : A,B,D,E

A.   Appetite:
The client has a good appetite, which is a positive sign of progress. A healthy appetite can indicate the resolution of some symptoms related to alcohol withdrawal, as well as an improvement in the client’s general health and nutrition. It also suggests that the client is physically stabilizing and no longer experiencing significant nausea or gastrointestinal issues that are common in alcohol withdrawal.
B.   Movement through the stages of grief:
The client has accepted the news about their parents' death and is moving through the stages of grief.
This is a significant step in emotional healing and demonstrates psychological progress. Acceptance of
the loss is a positive indicator of the client’s ability to cope with the bereavement, which is important for
long-term recovery, particularly given that grief and emotional stress contributed to the relapse.
C.   Cognition:
While cognitive status is important, there is no direct evidence presented that the client's cognition is specifically improving in this case. The nurses' notes do not mention any cognitive deficits or assessments directly related to cognition, and there are no significant changes to indicate cognitive improvement. This would require further assessment to determine if cognitive function is indeed progressing.
D.   Participation in group therapy:
Participation in group therapy is another key indicator of progress. Group therapy is an essential part of recovery for clients with alcohol use disorder, providing a supportive environment where clients can share their experiences and receive feedback from others. The fact that the client is attending group therapy shows engagement in their treatment plan and is likely helping the client with social support and recovery-focused education.
E.   Client resolves to limit alcohol consumption:
The client has resolved to limit alcohol consumption, which is a clear and positive commitment to change. This suggests that the client is taking responsibility for their recovery and recognizes the need for behavioral change to prevent future alcohol use. Such a commitment is a crucial step in overcoming alcohol use disorder and achieving long-term sobriety.

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Correct Answer is A

Explanation

A. The nurse should assess the client’s need for toileting regularly, as restricted movement can increase the risk of discomfort and physical harm. Monitoring this every 15 minutes is recommended for ensuring the client's basic needs are met.
B. Physical restraint prescriptions should be renewed at intervals that are consistent with the facility’s
policies, but every 8 hours is typically too long. A more frequent reassessment should occur.
C. Clients in restraints should be monitored more frequently than every 30 minutes to ensure their safety and well-being, especially in terms of physical comfort and circulation.
D. Offering hydration and nutrition every 2 hours may not be necessary if the client is receiving fluids and food regularly, but they should be monitored more frequently for other immediate needs.

A. "Ask a family member to check the locks for you at night." B. "Focus on abdominal breathing whenever you go to check the locks." C. "Keep a journal of how often you check the locks each night." D. "Snap a rubber band on your wrist when you think about checking the locks."

Correct Answer is D

Explanation

A. Having a family member check the locks may provide temporary relief but does not address the
client’s compulsive behaviors or promote self-control.
B. Abdominal breathing may help with anxiety, but it does not directly address the obsessive thoughts related to checking the locks.
C. Keeping a journal may help track the behavior, but it does not serve as an intervention for the compulsion itself.
D. Thought-stopping involves using a physical cue, such as snapping a rubber band, to interrupt the cycle of obsessive thinking and help the client refocus.

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A nurse is reviewing the day 5 vital signs and nurses' notes. Exhibits A nurse is evaluating the client's response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is reviewing the day 5 vital signs and nurses' notes.

Exhibits

A nurse is evaluating the client's response to treatment.

Select the 4 findings that indicate the client is progressing with their plan of care.