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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Blood culture is essential to identify any potential infection that the patient may have, which is a common complication after trauma.
B . Prothrombin time is crucial for assessing the blood's clotting ability, especially since the patient has a suspected fracture and could be at risk of bleeding.
C . Hemoglobin and hematocrit are fundamental tests to evaluate for anemia or blood loss, which is particularly relevant given the patient's fall and the possibility of internal injuries. D . Type and screen is necessary in case the patient requires a blood transfusion due to the injuries sustained from the fall.
E . Albumin is not typically a priority in acute trauma settings and would not necessarily be expected as an immediate test.
F . Lipid panel is not relevant in the acute management of trauma and is not typically ordered in the emergency setting
Correct Answer is []
Explanation
Actions to Take:
A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic
autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its
progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes.
B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity.
Potential Condition:
D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment.
Parameters to Monitor:
C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies.
D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.
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