A nurse is reviewing the day 5 vital signs and nurses' notes.
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.
Participation in group therapy
Movement through the stages of grief
Client resolves to limit alcohol consumption
Appetite
Cognition
Vital signs
Correct Answer : A,B,E,F
A. Participation in group therapy - This indicates the client's engagement in therapeutic interventions, suggesting progress in addressing their alcohol use disorder and coping with grief.
B. Movement through the stages of grief - Progress in processing grief is a positive sign of emotional healing and adjustment.
C. Client resolves to limit alcohol consumption - While resolution to limit alcohol consumption would be an ideal outcome, there is no specific indication in the scenario that the client has made this resolution.
D. Appetite - Although improvement in appetite would be a positive sign, there is no specific mention of the client's appetite in the provided information, so it cannot be assumed that this finding indicates progress in the client's plan of care.
E. Cognition - Improvement in cognition suggests a reduction in the effects of alcohol intoxication or withdrawal, indicating progress in treatment.
F. Vital signs - Stable vital signs within normal range suggest physiological stability and potentially a positive response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Blaming others for one's own mistakes is not typically associated with PTSD. Individuals with PTSD may have heightened irritability or anger, but this does not necessarily translate to blaming others.
B. Difficulty concentrating on tasks is a common symptom of PTSD as individuals may be easily distracted by intrusive thoughts related to their trauma.
C. Difficulty falling or staying asleep is another symptom often reported by individuals with PTSD, which can be attributed to hyperarousal and intrusive thoughts.
D. Holding persistent negative beliefs about oneself is indicative of the negative alterations in cognition and mood associated with PTSD.
E. Talking excessively is not a common finding in PTSD. While some individuals may speak more when anxious, it is not a diagnostic criterion for PTSD.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.
Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.
Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.
Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.
Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.
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