atient Data

Exhibits

The nurse reviews the H and P and nurses' note.

Complete the diagram by dragging from the choices area to specify which condition the family is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess family coping.

Answer and Explanation

The Correct Answer is []

Potential Condition: Anticipatory Grief

Anticipatory grief occurs before a significant loss, such as a loved one’s death, when the loss is expected. The family in this case is emotional, shocked, and showing signs of distress in response to the impending loss, indicating anticipatory grief rather than complicated or ambiguous grief.

Actions to Take:

Provide information on grief support groups: Giving the family access to community and professional support prepares them to cope during and after the loss.

Encourage and allow the family to express their feelings: Expressing emotions like sadness, anger, or disbelief is part of the grieving process. Validating these emotions helps families process anticipatory grief in a healthy way.

Parameters to Monitor:

Monitor for signs of masked grief: Some family members may suppress emotions, redirect their distress, or act in denial, which could hinder healthy coping and grieving.

Monitor for intense pain responses: These responses can indicate overwhelming or dysfunctional grief that may need additional psychological support or counseling.

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Correct Answer is D

Explanation

A. Remove dentures or other oral appliance: While this may be appropriate for some clients during sleep, it is not a specific intervention that addresses the airway obstruction caused by sleep apnea.

B. Elevate the head of the bed to a 45-degree angle: Elevation can help with breathing but is not as effective as using the prescribed positive airway pressure device in managing obstructive sleep apnea.

C. Lift and lock the side rails in place: This is a general safety measure, not specific to preventing airway obstruction during sleep in clients with OSA.

D. Apply the client's positive airway pressure device: The CPAP or BiPAP device keeps the airway open during sleep and is the primary and most effective intervention to prevent apnea episodes, making this the most important action before leaving the client alone.

A. An older adult with left sided weakness. B. An adult client with enuresis C. An adult client with polyuria. D. An older adult with a right hip fracture.

Correct Answer is D

Explanation

A. An older adult with left sided weakness: This client may require assistance to ambulate or use a bedside commode, but depending on strength and stability, they might still be able to use the toilet with support rather than needing a bedpan.

B. An adult client with enuresis: Enuresis refers to involuntary urination, often during sleep. This condition is not an indication for a bedpan, as the focus would be on continence management rather than assisted toileting.

C. An adult client with polyuria: Increased urine output due to polyuria does not necessarily impair mobility. Unless the client is immobile, they can use a toilet or commode rather than a bedpan.

D. An older adult with a right hip fracture: A hip fracture significantly impairs mobility and weight-bearing ability, making it unsafe to ambulate to the bathroom or commode. A bedpan is typically required until mobility is restored or stabilized.

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Naxlex Comprehensive Predictor Exams

The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is D

Explanation

The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?

Correct Answer is D

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

A client requests heat therapy for lower back pain. Which action should the nurse take?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Patient data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?