Exhibits here

The nurse is implementing solutions to provide care.

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

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

A. being cold: Being cold is not directly related to the symptoms described in the scenario.

The client's symptoms include dizziness, headache, burning feeling on extremities, and redness on face and extremities, but there is no mention of feeling cold.
B.   dyspnea: Dyspnea, or difficulty breathing, may occur as a result of an adverse reaction such as anaphylaxis or severe cardiovascular compromise. It is a concerning symptom that warrants immediate attention and intervention.

C.   shaking: Shaking is not mentioned in the client's symptoms in the scenario. While it can be a sign of distress or discomfort, it is not directly related to the symptoms of dyspnea, nausea, and headache described.
D.   nausea: Nausea is a common symptom associated with adverse reactions to medications, including allergic reactions or cardiovascular events. It can contribute to the client's overall discomfort and may indicate ongoing or worsening adverse effects.
E.   blood pressure 116/68 mm Hg: The client's blood pressure of 116/68 mm Hg is not

indicative of ongoing adverse reactions. While the initial blood pressure reading was low (108/46 mm Hg), it is not included as part of the ongoing symptoms described.
F. headache: Headache can be a manifestation of various adverse reactions, including allergic reactions or changes in blood pressure. It is a symptom that should be monitored closely as it can indicate ongoing or worsening complications.

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

Explanation

A. Ask if the client is experiencing any pain with urination. Urinary tract infections (UTIs) are common in older adults and can lead to sudden changes in behavior, including confusion and agitation.
B. Determine if the client has recently experienced a fall. Falls can lead to head injuries or other trauma that may cause confusion or changes in behavior in older adults.
C. Provide instruction on taking the client's temperature. Fever can be a sign of infection, which might be causing the sudden behavioral changes. Monitoring temperature can help identify if an infection is present.
D. Encourage increased intake of high protein foods. While good nutrition is important, it is not directly related to the sudden onset of confusion and agitation, making this a less immediate priority.
E. Review the client's current food and medication allergies. Allergic reactions to foods or
medications can cause sudden behavioral changes. Reviewing allergies can help determine if this is the cause of the symptoms.

Correct Answer is []

Explanation

- Potential Condition:

Stage 2 pressure injury

- Actions to Take:

C. Clean the area and dry carefully: Proper wound care involves cleaning the area to prevent infection and promote healing. Cleaning the erythematous area on the left heel and ensuring
it is dry can help prevent further skin breakdown and promote healing.

B. Hold the hydrochlorothiazide: Hydrochlorothiazide is a diuretic that can increase urine output and potentially lead to dehydration, which may exacerbate the client's condition. Holding the medication temporarily can help prevent further fluid loss and dehydration, which is crucial for wound healing.

- Parameters to Monitor:

B. Skin color: Monitoring the skin color around the erythematous area on the left heel can help assess tissue perfusion and identify any signs of deterioration or improvement in the wound condition.
D. Fluid balance: Monitoring the client's fluid balance, including intake and output, is essential for assessing hydration status and ensuring adequate tissue perfusion, which is vital for wound healing and overall patient well-being.

Exhibits

The nurse is implementing solutions to provide care.

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

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
, dropdown
 and dropdown

View Question and Answer

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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

Correct Answer is []

Explanation

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

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In providing nursing care for a client after gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

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