Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

"I can learn to manage my thoughts better through therapy."

"This diagnosis means that I am crazy."

"Many people have the same response to a stressful situation as I am having right now."

"I can use holistic approaches like meditation to help my symptoms."

"I will probably need to be on medication for the rest of my life."

"I am at high risk for post-traumatic stress disorder because I have acute stress disorder."

Answer and Explanation

Correct Answer : B,E,F

B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.

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Correct Answer is C

Explanation

Rationale

A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.

B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.

C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.

D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.

A. Nausea and headache. B. Watery diarrhea. C. Increased fatigue. D. Yellow-tinged sputum.

Correct Answer is B

Explanation

Rationale

A. Nausea and headache are common side effects of linezolid. While they can impact the client's comfort and adherence to treatment, they are generally not considered urgent or life-threatening unless severe or persistent.

B. Watery diarrhea is a significant concern with linezolid therapy, as it can indicate the development of Clostridium difficile infection (CDI) or other types of antibiotic-associated diarrhea. CDI is a severe condition that requires prompt treatment to prevent complications such as dehydration, colitis, and potentially life-threatening outcomes like toxic megacolon.

C. Increased fatigue can be a nonspecific symptom and may result from various factors, including the underlying illness (nosocomial pneumonia), medication side effects, or the stress of hospitalization. While it should be monitored, it is typically not an immediate concern unless accompanied by other concerning symptoms.

D. Yellow-tinged sputum can indicate the presence of infection or inflammation in the respiratory tract, which is relevant in the context of nosocomial pneumonia. It could suggest a worsening of the pneumonia or a new infection. However, it is not typically directly associated with linezolid therapy itself.

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Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.