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 {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Upon assessment, the nurse should recognize that the client is at risk for developing acute confusion or delirium as evidenced by the client's disorientation to time and place, inability to focus, agitation, and anxiety upon reorientation. These symptoms suggest a disruption in cerebral metabolism, which can be caused by a variety of factors such as infection, fluid or electrolyte imbalance, or medication side effects. It is crucial to identify the underlying cause to provide appropriate care and prevent further complications. The nurse's role includes monitoring the patient's mental status, ensuring safety, and implementing therapeutic interventions to create a calming environment.
Correct Answer is C
Explanation
A. Orientation to person, place, and time is important for assessing mental status but may not necessarily indicate the need for restraint removal.
B. Self-harm threats should be taken seriously but may require further assessment and intervention rather than immediate restraint removal.
C. The ability to follow commands indicates a level of cooperation and self-control, which may warrant removal of restraints as the client can potentially be managed without them.
D. Refusal to take medication may necessitate further intervention but may not directly indicate the need for restraint removal unless it poses an immediate risk to the client's safety.
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