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Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

Acknowledge feelings of anxiety.

Weigh the client twice weekly.

Encourage exercise.

Provide family education on the condition.

Monitor trips to the restroom.

Allow for menu deviations.

Set precise mealtimes.

Answer and Explanation

Correct Answer : A,B,D,E,G

A. Acknowledge feelings of anxiety: The client's neurological assessment indicates agitation, and acknowledging this can help in addressing any underlying anxiety.
B. Weigh the client twice weekly: Given the client's low BMI and the mother's concern about her weight, regular monitoring is necessary.
C. Encourage exercise: While exercise is generally healthy, the client's current bradycardia and low BMI suggest that immediate physical exertion may not be advisable without medical
supervision.
D. Provide family education on the condition: The client's mother's concern and the client's defensiveness about her weight indicate a need for family education.
E. Monitor trips to the restroom: Monitoring is important to ensure the client is not engaging in behaviors that could further compromise her health, such as purging.
F. Allow for menu deviations is incorrect. Allowing menu deviations can enable the client to avoid certain foods, which reinforces disordered eating behaviors. Structured, balanced meals are essential for recovery.

G. Set precise mealtimes is correct because establishing structured mealtimes promotes consistency and reduces anxiety related to eating. This helps the client develop healthier eating patterns and decreases the urge to binge or purge.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Frequent premature ventricular contractions: While abnormal heart rhythms are a concern, they may not warrant immediate intervention in this context unless they are causing significant hemodynamic instability.
B. Paroxysmal supraventricular tachycardia: This cardiac dysrhythmia may require intervention but is not directly related to the administration of alteplase.
C. Lower extremity edema: Lower extremity edema may indicate venous insufficiency or other underlying conditions but is not directly related to the administration of alteplase.
D. Headache with blurred vision: This could be indicative of worsening cerebral edema or increased intracranial pressure, which are potential complications of alteplase administration and require immediate intervention.

A. Inspiratory and expiratory bilateral crackles. B. Average urine output of 28 mL/hour. C. Vesicular bibasilar breath sounds. D. Central venous pressure of 12 mm Hg.

Correct Answer is A

Explanation

A. Inspiratory and expiratory bilateral crackles indicate fluid overload or pulmonary edema, which can be life-threatening and requires immediate intervention. This condition can impair gas exchange and lead to respiratory distress or failure if not promptly addressed.

B. An average urine output of 28 mL/hour is below the expected minimum of 30 mL/hour for adults, indicating potential renal impairment or inadequate fluid resuscitation. While concerning, it is not as immediately life-threatening as pulmonary edema.

C. Vesicular bibasilar breath sounds are normal breath sounds heard at the bases of the lungs and do not indicate any immediate respiratory distress or fluid overload. This finding does not warrant urgent intervention.

D. A central venous pressure (CVP) of 12 mm Hg is within the upper normal range (8-12 mm Hg) and suggests adequate fluid resuscitation. It does not indicate fluid overload or other immediate concerns requiring urgent intervention.

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Exhibits Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

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The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

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Exhibits

Which interventions are indicated to promote positive outcomes for the client? Select all that apply.