A nurse is reviewing the day 5 vital signs.

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.

Vital signs

Movement through the stages of grief

Cognition

Participation in group therapy

Appetite

The client resolves to limit alcohol consumption

Answer and Explanation

Correct Answer : A,B,D,E

Choice A Reason: Vital signs are a critical indicator of a patient’s health status. Normal ranges for vital signs in a resting adult include a body temperature of 97.8°F to 99.1°F (36.5°C to 37.3°C), blood pressure between 90/60 mmHg and 120/80 mmHg, a pulse rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 18 breaths per minute. The client’s vital signs have stabilized from the initial erratic readings to within normal ranges by hospital day 5, indicating a positive response to the treatment plan.
Choice B Reason: Movement through the stages of grief is essential for emotional recovery, especially in the context of alcohol use disorder where the grief may have triggered the relapse. The stages of grief include denial, anger, bargaining, depression, and acceptance. Progress in these stages can be a sign of emotional healing and a successful coping mechanism in the recovery process.
Choice D Reason: Participation in group therapy is a key component of substance use disorder treatment. It provides social support, reduces isolation, and helps develop effective communication and interpersonal skills3. Active participation in group therapy sessions indicates the client’s engagement with the treatment process and their commitment to recovery.
Choice E Reason: Appetite changes are common during recovery from alcohol use disorder. Initially, there may be a loss of appetite due to the effects of alcohol on the gastrointestinal system and overall health. However, as recovery progresses, appetite usually returns, and the individual may even overeat5. An improvement in appetite suggests that the client’s physical health is improving and that they are regaining a normal relationship with food.

Choice C Reason: Cognition refers to the mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging, and problem-solving. These are higher-level functions of the brain and encompass language, imagination, perception, and planning. A person’s cognitive ability can be affected by alcohol use disorder, as alcohol can impair cognitive functions and damage brain structures. However, recovery from alcohol abuse can lead to improvements in cognitive functions. Research indicates that most noticeable improvement in cognitive function begins after one year of abstinence from alcohol. Therefore, if the client shows signs of improved cognition, such as better memory, clearer thinking, or improved problem-solving, it would indicate progress in their recovery.
Choice F Reason: The client’s resolve to limit alcohol consumption is a significant indicator of their commitment to long-term recovery. Setting limits on alcohol intake is a crucial step in the process of recovery and can help prevent relapse. For men, moderate drinking is defined as up to two drinks per day and for women, up to one drink per day3. If the client expresses a desire to limit their alcohol consumption to within these guidelines, or better yet, abstains from alcohol completely, it would demonstrate a positive change in behavior and mindset towards their health and recovery.

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Correct Answer is B

Explanation

Choice A reason: Asking "Why did you feel like giving away your belongings?" could be perceived as confrontational or judgmental. It's important to approach the client with empathy and without implying that their actions were wrong or require justification.

Choice B reason: "Can you tell me how you have been feeling lately?" is an open-ended question that invites the client to share their feelings and experiences. It demonstrates the nurse's interest in understanding the client's emotional state and provides a safe space for the client to express themselves.

Choice C reason: Saying "Everyone feels a little down sometimes." minimizes the client's experience and the severity of major depressive disorder. It fails to acknowledge the unique and serious nature of the client's condition.

Choice D reason: While suggesting "You should find a support group to attend." can be helpful, it may be more appropriate after establishing a rapport and understanding the client's current state. It's also important to offer support in finding resources rather than directing the client.

A. "Have you talked to your family about your diagnosis?" B. "These feelings are an expected part of anticipatory grieving." C. "I'm sure the nurses are trying to take good care of you." D. "Can you tell me more about what is upsetting you?"

Correct Answer is D

Explanation

Choice A reason: While discussing the client's diagnosis with their family could be part of the care process, it does not address the client's immediate concern about the quality of care they are receiving. This response does not validate the client's feelings or provide an opportunity for them to elaborate on their concerns.

Choice B reason: Telling the client that their feelings are part of anticipatory grieving may be true, but it can come across as dismissive and does not offer support for the specific issue the client has raised about the quality of care.

Choice C reason: Assuring the client that the nurses are trying to provide good care does not acknowledge the client's perception of inadequate care. It's important to validate the client's feelings and understand their perspective before offering reassurances.

Choice D reason: Asking the client to elaborate on their concerns shows empathy and a willingness to listen. It allows the nurse to gather more information about the client's experience and identify specific areas that may need improvement in the care provided.

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A nurse is reviewing the day 5 vital signs. 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and states that they have given away their personal belongings. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving end-of-life care. The client states, "The nurses here don't do a good job caring for me." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

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A nurse is reviewing the day 5 vital signs.

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.