A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?

Maintain trust and avoid behaviors that may increase agitation.

Order the client to go to their room & alert security.

Tell the client to sit down or risk isolation and loss of privileges.

Sedate the client after collecting a lithium level.

Answer and Explanation

The Correct Answer is A

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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Correct Answer is A

Explanation

This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.

This is a serious condition that requires immediate medical attention.

Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.

It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.

Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.

It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.

Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.

It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.

Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.

A. Report of joint pain by a client who recently started taking arthritis medication. B. Report of decreased appetite and difficulty sleeping. C. Weight loss of two pounds in a client admitted in congestive heart failure. D. Diminished breath sounds in a client admitted with pneumonia.

Correct Answer is D

Explanation

Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.

The healthcare provider should be notified immediately to assess the client and order appropriate interventions.

Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.

Joint pain is a common symptom of arthritis and may take some time to improve with medication.

The nurse should monitor the client’s pain level and administer analgesics as prescribed.

Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.

These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.

The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.

Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.

Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.

The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.

Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been taking aspirin 325 mg six to eight times a day for the past two weeks to control pain from a knee injury. Which symptom reported by the client should the nurse report to the health care provider (HCP) for priority follow-up?

Correct Answer is A

Explanation

Which client assessment should a nurse immediately report to the health care provider?

Correct Answer is D

Explanation

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A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

Which action will prevent spreading organisms from one eye to the other when bathing a client?

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?