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.

Answer and Explanation

The Correct Answer is []

Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan.

Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema.

Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.

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Correct Answer is D

Explanation

A. Observing body language and movement can provide valuable information about pain, but it doesn't directly assess the quality of the pain. It's more indicative of the client's physical response to pain rather than the pain itself.
B. Identifying effective pain relief measures is important for pain management but doesn't directly assess the quality of the pain. This approach focuses on interventions rather than understanding the nature of the pain.
C. Providing a numeric pain scale can quantify the intensity of pain, but it doesn't necessarily assess the quality of the pain. While useful for tracking pain levels over time, it doesn't provide insights into the characteristics or nature of the pain.
D. Asking the client to describe the pain allows for a subjective assessment of its quality,
intensity, duration, and any associated symptoms. This approach provides valuable information for tailoring pain management strategies and understanding the client's experience.

A. Observe color of urine. B. Assess skin turgor. C. Measure body temperature. D. Check for pedal edema.

Correct Answer is A

Explanation

A. Observing the color of urine is crucial when monitoring for adverse effects of prasugrel, as one of the potential adverse effects is bleeding. Hematuria (blood in the urine) can indicate
bleeding complications, which require immediate attention.
B. Assessing skin turgor is not directly related to monitoring for adverse effects of prasugrel.
Skin turgor assessment is typically used to assess hydration status.
C. Measuring body temperature is important for monitoring for signs of infection or inflammation but is not directly related to monitoring for adverse effects of prasugrel.
D. Checking for pedal edema is not directly related to monitoring for adverse effects of
prasugrel. Pedal edema may indicate issues such as fluid overload or venous insufficiency.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?

A client presents to the emergency department (ED reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

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?

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

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.