Exhibits

The nurse evaluates the client findings.

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

The nurse evaluates the client and determines there are concerning symptoms, including subjective symptoms of
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and
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.

Answer and Explanation

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

Rationale for Correct Choices:

Sleeping difficulty: The client reports insomnia, a core symptom of post-traumatic stress disorder (PTSD) and depression. Sleep disturbances are common among individuals with trauma exposure and are particularly concerning when paired with suicidal ideation.
Hypervigilance: The client's constant surveying of the environment and being easily startled are hallmark signs of hypervigilance. This symptom reflects heightened arousal often seen in PTSD, especially in veterans who have experienced combat trauma.

Rationale for Incorrect Choices:

Withdrawn mood: While the client appears quiet and withdrawn, this behavior is more observational than subjective. The question asks for subjective symptoms, which are the client’s personal experiences rather than behaviors noted by others.
Alcohol on breath: The presence of alcohol on the breath is an objective clinical finding, not a subjective symptom reported by the client. Although relevant to her condition, it doesn’t fulfill the criteria specified in the prompt.
Blood pressure of 144/92 mmHg: This is an objective vital sign and not a subjective symptom. Elevated blood pressure may be due to anxiety but is not something the client reports feeling.
Nightmares: Though she has nightmares, this was part of the background history already acknowledged. Hypervigilance is more acute and directly observable during this clinical encounter.
Latency of response: While the client requires prodding to give answers, this is an observed behavior and not a reported internal experience, so it does not qualify as a subjective symptom.
Respirations of 20 breaths/minute: This is an objective clinical measurement. It may suggest anxiety, but it is not subjectively reported by the client.

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Correct Answer is A

Explanation

Rationale:
A. Ask the client to describe the pain: Describing the pain in the client's own words helps determine the pain’s quality, such as whether it's throbbing, stabbing, or dull. This subjective data is critical for diagnosing migraine type. It provides insight into patterns and guides individualized treatment options.

B. Provide a numeric pain scale: The numeric pain scale measures intensity, not quality, of pain. While important, it does not offer specific details on the sensation or nature of the migraine. It is more effective for tracking changes in pain severity over time.

C. Identify effective pain relief measures: This evaluates which interventions are working, not the type of pain being experienced. It is valuable for long-term management but doesn't assist with assessing the sensory qualities of current pain..

D. Observe body language and movement: Observation gives indirect clues about pain presence but not quality. Body language may suggest discomfort, yet it cannot replace verbal descriptions of the pain's nature.

A. Recent change in the ability to read and drive after dark. B. Gradual onset of continuous eye pain and blurred vision. C. Cloudy opacity of the crystalline lens. D. Gray-white circle around the iris of both eyes.

Correct Answer is B

Explanation

Rationale:

A. Recent change in the ability to read and drive after dark: This may indicate the onset of cataracts or age-related night vision decline, which is common in older adults. While it should be documented and followed up, it is not considered an urgent or emergent finding.

B. Gradual onset of continuous eye pain and blurred vision: This may suggest the development of angle-closure glaucoma or another serious ocular pathology, where increasing intraocular pressure could lead to permanent vision loss if not treated promptly.

C. Cloudy opacity of the crystalline lens: A cloudy lens is characteristic of cataracts, a common, non-urgent age-related change in older adults. Although it affects vision over time, it progresses slowly and can be addressed during routine follow-up care or elective surgery.

D. Gray-white circle around the iris of both eyes: This describes arcus senilis, a benign finding caused by lipid deposits in the corneal margin. It is common with aging and usually has no impact on vision or underlying pathology requiring urgent referral unless seen in younger adults.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

Correct Answer is A

Explanation

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

Correct Answer is B

Explanation

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