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Exhibits

Chart data is reviewed.

Drag from Word Choices to complete the sentence.

Client symptoms are indicators of

.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A"}

Rationale for Correct Choice:

  • Depression: The client has symptoms of depression, such as general malaise, fatigue, decreased appetite, withdrawal, flat affect, and poor hygiene. Additionally, the client reports a significant change in sleep patterns, with an inability to sleep at night. His alcohol consumption could also contribute to depressive symptoms.

Rationale for Incorrect Choices:

  • Anxiety disorder: While anxiety can cause fatigue, disrupted sleep, and lack of energy, it typically also presents with heightened nervousness, restlessness, excessive worry, or physical symptoms like rapid heart rate, which are not reported here. The client's withdrawal and lack of energy are more consistent with depression.
  • Hypothyroidism: Hypothyroidism can cause fatigue, weight gain, and poor appetite, but the client's low BMI (17.7 kg/m²) suggests that weight loss, rather than gain, is occurring. Additionally, the lack of other hypothyroid symptoms, like constipation or cold intolerance, makes hypothyroidism less likely than depression in this scenario.


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Related Questions

Correct Answer is ["B","C","E"]

Explanation

A. Explain expected side effects of postoperative chemotherapy: Chemotherapy and its side effects are typically discussed after surgery when the treatment plan is clearer. The focus before surgery should be on preparing the child and family for the surgery itself.

B. Monitor blood pressure every 2 hours for hypertension: Wilm's tumor can be associated with hypertension due to renin production from the tumor, so monitoring the child's blood pressure closely is essential to detect any signs of hypertension early.

C. Provide parents with simple explanations and repeat often: Simplified, repeated explanations are key to helping parents understand the diagnosis and surgical procedure. This approach supports emotional comfort and ensures informed decision-making.

D. Attend all healthcare provider and parent conferences: While it is important to support the family, the nurse’s role in attending all healthcare provider and parent conferences is not mandatory unless specifically needed for continuity of care.

E. Measure the child's abdominal girth: Measuring abdominal girth is essential preoperatively to monitor for any abdominal changes, such as swelling or distension, which could indicate tumor growth or other complications related to the Wilm's tumor.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

  • Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
  • Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
  • Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
  • Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.
  • Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
  • Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.

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