On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate 125 beats/minute, respiratory rate 36 breaths/minute, and blood pressure 166/88 mm Hg. Which nursing intervention(s) should the nurse implement? (Select all that apply.)

Present a calm, supportive demeanor.

Reorient to day and time frequently.

Administer an as needed (PRN) dose of lorazepam.

Turn the television on for distraction.

Apply soft wrist restraints bilaterally.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Presenting a calm, supportive demeanor is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust.

Choice B reason: Reorienting to day and time frequently is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control.

Choice C reason: Administering an as needed (PRN) dose of lorazepam is an appropriate intervention for a client who is experiencing anxiety and hallucinations. Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication.

Choice D reason: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client.

Choice E reason: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.

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Correct Answer is B

Explanation

Choice A reason: Using incentive spirometer is not an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it is not related to the procedure or the condition. The incentive spirometer is a device that helps improve lung function and prevent respiratory complications by encouraging deep breathing and coughing. Therefore, this choice is incorrect.

Choice B reason: Monitoring urinary stream for decrease in output is an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it can indicate urinary retention or obstruction, which are potential complications of the procedure. The client should report any difficulty or inability to urinate, severe pain, or fever to the health care provider. Therefore, this choice is correct.

Choice C reason: Reporting when hematuria becomes pink tinged is not an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, because it is not a sign of a problem. Hematuria, or blood in the urine, is a common and expected finding after the procedure, and it usually resolves within a few days. The client should drink plenty of fluids to flush out the blood clots and debris. Therefore, this choice is incorrect.

Choice D reason: Restricting physical activities is an information that the nurse should include in the discharge instructions for a client with BPH following a TUNA, but it is not the best answer. The client should avoid strenuous activities, such as lifting heavy objects, driving, or sexual intercourse, for at least two weeks after the procedure to prevent bleeding and infection. However, this information is less important than monitoring urinary stream for decrease in output. Therefore, this choice is not the best answer.

A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result. B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages. C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms. D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.

Correct Answer is B

Explanation

Choice A reason: This is incorrect because the humoral immune response involves B cells that produce antibodies against specific antigens. However, AIDS affects the cellular immune response, which involves T cells that activate other immune cells and directly kill infected cells.

Choice B reason: This is correct because AIDS is caused by human immunodeficiency virus (HIV), which infects and destroys CD4+ T cells, also known as helper T cells. These cells are essential for initiating and regulating both humoral and cellular immunity. Without enough CD4+ T cells, the body cannot mount an effective response against pathogens, especially opportunistic infections that take advantage of a weakened immune system.

Choice C reason: This is incorrect because bone marrow suppression of white blood cells is not a direct consequence of AIDS. However, some drugs used to treat AIDS, such as zidovudine, may cause bone marrow suppression as a side effect.

Choice D reason: This is incorrect because exposure to multiple environmental infectious agents does not cause AIDS. However, people with AIDS are more susceptible to infections from various sources due to their impaired immune system.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA), which information should the nurse include in the discharge instructions?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?