Exhibits

The nurse has completed a client history and initial assessment and is now planning on prioritizing care of the client.

Complete the following sentences by choosing from the list of corresponding options

Based on the history and assessment data, the nurse should prioritize
dropdown
as the priority problem for this client, as evidenced by the client's statement,
dropdown
.

Answer and Explanation

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

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.

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Correct Answer is B

Explanation

Choice A reason: Massage therapy can help with relaxation and improving circulation in some cases, but it is not a primary intervention for managing PAD. Structured exercise is more effective in improving symptoms and overall cardiovascular health.

Choice B reason: Structured exercise is the most appropriate intervention for a client with PAD. Regular physical activity, especially walking, can help improve blood flow, reduce symptoms, and enhance overall cardiovascular health. It is recommended that clients with PAD engage in a supervised exercise program to ensure safety and effectiveness.

Choice C reason: A carnivore diet is not recommended for clients with PAD. A heart-healthy diet that includes a variety of fruits, vegetables, whole grains, lean proteins, and healthy fats is more beneficial for managing PAD and reducing cardiovascular risk factors.

Choice D reason: Leg elevation can help reduce swelling and improve comfort, but it is not a primary intervention for managing PAD. Structured exercise has a more significant impact on improving blood flow and reducing symptoms.

A. Hypotension and venous pooling in the extremities B. Reports of chest pain and shortness of breath C. Pain and a burning sensation upon urination and hematuria D. Profuse diaphoresis and severe, pounding headache

Correct Answer is D

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.

Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.

Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.

Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.

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Naxlex Comprehensive Predictor Exams

A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Correct Answer is B

Explanation

A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is D

Explanation

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

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