Exhibits

The nurse reviews the client's data.

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

The client's assessment findings of
dropdown
and
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places him at a high risk for multiple other health issues and requires immediate follow up by the nurse.

Answer and Explanation

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

The client's assessment findings of neuropathy and incontinence place him at a high risk for multiple other health issues and require immediate follow-up by the nurse.

Rationale:

Neuropathy. The client reports neuropathy in both hands and lower legs. Neuropathy leads to decreased sensation, increasing the risk of falls, pressure injuries, and unnoticed wounds, which can become severe due to diabetes-related poor healing. It also contributes to mobility limitations, further affecting the client’s safety and independence.

Incontinence. The client experiences urinary and fecal incontinence due to difficulty moving quickly enough to reach the bathroom. Incontinence increases the risk of skin breakdown, infections, and pressure ulcers, especially since the client has mobility issues and spends prolonged time sitting.

Moist skin. While moist skin may suggest sweating or autonomic dysfunction, it is not as significant a risk factor as neuropathy and incontinence, which directly impact skin integrity and mobility.

Coarse lung sounds. Coarse lung sounds may indicate fluid retention or respiratory congestion, but they are not as immediately concerning as neuropathy and incontinence, which increase the risk for skin damage, infection, and functional decline.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Offer a low sodium formula between breast feedings. Congenital hypothyroidism is not managed with dietary sodium restrictions. The priority is thyroid hormone replacement, not sodium intake adjustments.
B. Stimulate the infant during feedings to ensure adequate intake. Infants with congenital hypothyroidism may have poor feeding due to lethargy, but stimulation during feedings is not the primary intervention. The most critical aspect of care is thyroid hormone replacement to support normal growth and brain development.
C. Administer supplemental thyroid hormone daily. Lifelong thyroid hormone replacement with levothyroxine is essential to prevent intellectual disability and growth delays. Early and consistent treatment ensures normal neurological and physical development. Missing doses or delaying treatment can result in irreversible cognitive impairment.
D. Monitor the infant's daily intake and weekly weight. While monitoring growth and nutrition is important, it is secondary to ensuring proper thyroid hormone therapy, which directly affects metabolism, weight gain, and developmental outcomes.

A. Offer to also administer a meningococcal vaccine to the client. B. Record height, weight, and vital signs before giving the vaccine. C. Ask if the client's influenza exposure was within the last week. D. Review the client's vaccination history in the electronic record.

Correct Answer is D

Explanation

A. Offer to also administer a meningococcal vaccine to the client. The meningococcal vaccine is not routinely recommended for older adults unless they are at increased risk (e.g., immunocompromised, asplenic, or in certain outbreak situations). The priority is ensuring the influenza vaccine is appropriate based on the client’s history.
B. Record height, weight, and vital signs before giving the vaccine. Routine height, weight, and vital signs are not necessary before administering an influenza vaccine unless the client has symptoms of illness. The focus should be on vaccination history and contraindications.
C. Ask if the client's influenza exposure was within the last week. Recent exposure to influenza does not contraindicate vaccination. The vaccine is preventive and does not provide immediate protection, so the client should still receive it to help prevent future infection.
D. Review the client's vaccination history in the electronic record. Checking vaccination history ensures the client is receiving the correct vaccine and has not already been vaccinated for the season. This helps prevent unnecessary repeat doses and ensures adherence to recommended immunization schedules.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

Correct Answer is D

Explanation

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Which client has the highest risk for developing skin cancer?

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