Exhibits

The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.

Complete the following sentence by choosing from the lists of options.

Based on the information collected, the client is likely experiencing
related to

Answer and Explanation

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

Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure

Rationale

The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.

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Correct Answer is B

Explanation

A. While fatigue can contribute to decreased appetite, it is not as directly linked to the specific condition of trigeminal neuralgia.
B. Trigeminal neuralgia is characterized by severe, sharp facial pain, often triggered by chewing, talking, or even a gentle breeze. This pain would significantly deter a person from eating, leading to imbalanced nutrition.
C. Nausea is not a typical symptom of trigeminal neuralgia and would not be the primary cause of imbalanced nutrition in this case.
D. While altered taste can affect food enjoyment, it is less likely to completely deter someone from eating compared to the intense pain associated with trigeminal neuralgia.

A. Take the diuretic every day, regardless of weight loss or muscle weakness. B. Weigh yourself daily at the same time and report excessive weight loss. C. Limit fluid intake while taking the diuretic to reduce fluid retention. D. Stop taking the medication when the edema in the lower extremities subsides.

Correct Answer is B

Explanation

A. Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B. Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C. Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D. Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

Correct Answer is B

Explanation

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Correct Answer is B

Explanation

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?