Exhibits

The nurse calms the client and deescalates the situation. The nurse notes that a diagnosis of posttraumatic stress disorder has been added to the care plan.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse recognizes that elevated
dropdown
can cause increased alertness and
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for Correct Choices:

Cortisol, epinephrine, and norepinephrine: These are key stress hormones activated during the fight-or-flight response. In PTSD, their persistent elevation is associated with symptoms like anxiety, agitation, and increased alertness, especially during perceived threats.
Hypervigilance: Hypervigilance refers to an enhanced state of sensory sensitivity and constant scanning of the environment for threats. It is a hallmark of PTSD, evident in the client's easily startled behavior and environmental scanning.

Rationale for Incorrect Choices:

Acetylcholine, epinephrine, and norepinephrine: Acetylcholine plays a greater role in attention and memory, not the stress response. Cortisol, not acetylcholine, is a more relevant hormone in PTSD-related hyperarousal and stress regulation.
Dopamine, norepinephrine, and epinephrine: While dopamine influences motivation and pleasure, cortisol is more directly tied to the physiological stress response seen in PTSD. Omitting cortisol weakens the connection to stress-induced hyperalertness.
Bradyphrenia: Bradyphrenia refers to slowed thinking, which is not typical in hyperaroused PTSD states. The client shows heightened awareness, not cognitive slowing.
Hypoactivity: Hypoactivity implies reduced movement or response, which does not align with the client’s constant environmental scanning and heightened alertness. Hyperactivity, not hypoactivity, is more consistent with hypervigilance.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Vitamin supplements for high-risk pregnant women: Primary prevention aims to prevent disease before it occurs. Providing supplements like folic acid helps reduce the risk of neural tube defects and promotes maternal-fetal health.

B. Lead screening for children in low-income housing: This is secondary prevention, as it involves early detection of a problem to allow for prompt intervention and reduce complications.

C. Regional relocation center for earthquake victims: This is a tertiary prevention or disaster response measure, aimed at managing the aftermath of an event rather than preventing it.

D. Case management and screening for clients with HIV: This is secondary and tertiary prevention focused on managing an existing condition and minimizing progression or complications.

A. Encourage activity as tolerated. B. Assess ability to swallow solids and liquids. C. Assist client with active range of motion. D. Reinforce deep breathing exercises. E. Obtain dietary consult for meal supplements.

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

Explanation

Rationale:
A. Encourage activity as tolerated: Gradual mobilization supports respiratory function, circulation, and muscle strength after prolonged intubation. Activity also helps reduce the risk of complications like atelectasis and deep vein thrombosis.

B. Assess ability to swallow solids and liquids: After extended intubation, clients are at risk for dysphagia, which can lead to aspiration pneumonia. A swallowing assessment is necessary to ensure safety before resuming a regular oral diet.

C. Assist client with active range of motion: Prolonged immobility in the ICU often leads to deconditioning and muscle weakness. Assisting with range of motion exercises promotes circulation, prevents contractures, and maintains joint flexibility.

D. Reinforce deep breathing exercises: Deep breathing promotes alveolar expansion, improves oxygenation, and prevents postoperative complications such as pneumonia or atelectasis, which are particularly concerning after extubation and in clients with COPD.

E. Obtain dietary consult for meal supplements: Poor appetite post-extubation can contribute to malnutrition and delayed recovery. A dietary consult ensures the client receives adequate caloric and protein intake through appropriate supplements.

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Naxlex Comprehensive Predictor Exams

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?

Correct Answer is A

Explanation

An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

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

Explanation

A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available?

A client shares with the nurse concerns of a possible stomach ulcer. The client is experiencing heartburn and a dull gnawing pain that is relieved with eating. Which is the best response by the nurse?

A client diagnosed with Parkinson's disease receives a prescription for carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning. Which information should the nurse include in the client's teaching plan? Select all that apply.

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?