Exhibits
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0900
Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking
requests sleeping medication for the night
keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep
can't seem to get out of this funk I am in
prefer to be in a quieter area of the unit
currently by the nurses' station
pain is 2 on a 0 to 10 pain scale
The Correct Answer is ["A","B","C","D"]
Rationale
The client is experiencing significant psychological distress characterized by intrusive thoughts and memories related to the traumatic event (house collapsing during a hurricane). These thoughts are causing her difficulty in falling asleep and impacting her emotional well-being. Her statement about feeling unable to get out of a "funk" suggests that she may be experiencing symptoms of acute stress or post-traumatic stress disorder (PTSD). It's crucial to address her psychological distress promptly to provide support and prevent exacerbation of her symptoms.
Sleep Difficulties: The client requests sleeping medication due to her difficulty in falling asleep. Sleep disturbances are common after experiencing a traumatic event and can further contribute to emotional distress and hinder recovery. It's important to assess her sleep patterns and consider appropriate interventions, such as pharmacological sleep aids under medical supervision, to help her achieve adequate restorative sleep.
Environment: The client expresses a preference for a quieter area of the unit away from constant noise (talking and alarms). Hospital environments can be noisy and disruptive, which can exacerbate anxiety and sleep difficulties. Ensuring she is in a quieter environment or making adjustments to minimize noise near her can improve her comfort and facilitate better sleep, which is essential for recovery and emotional well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12.5"]
Explanation
To calculate the dosage of amoxicillin suspension to be administered every 8 hours, one must first determine the total daily dosage in milligrams. Since 1 gram equals 1000 milligrams, 1.5 grams is equivalent to 1500 milligrams. This total daily dosage needs to be divided into three doses, as it will be administered every 8 hours.
Therefore, each dose will be 1500 mg divided by 3, which equals 500 mg per dose. The medication bottle states that there are 200 mg of amoxicillin in every 5 mL of suspension. To find out how many mL correspond to a 500 mg dose, set up a proportion: 200 mg/5 mL = 500 mg/x mL. Solving for x gives x = (500 mg * 5 mL) / 200 mg, which equals 12.5 mL
Therefore, the nurse should administer 12.5 mL of the amoxicillin suspension every 8 hours.
Correct Answer is B
Explanation
Rationale
A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.
B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.
C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.
D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.
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