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. Administering the placebo as prescribed when the client reports pain is ethically questionable.
Placebos are typically used in research or clinical trials and should not be administered without the client's informed consent and understanding.
B. While informing the charge nurse about the prescribed placebo is appropriate, refusing to administer it without further action may not address the ethical concerns surrounding placebo use.
C. Informing the client that the provider prescribed a placebo instead of pain medication is important for transparency and informed consent. However, this should be accompanied by discussing the ethical considerations with the healthcare provider.
D. Discussing ethical concerns about placebo use with the healthcare provider is the most appropriate intervention. This ensures that the nurse advocates for the client's well-being and addresses any potential ethical issues surrounding the use of placebos in pain management.

A. "I am happy that you are getting better and will be able to go home." B. "Tomorrow I will talk to that nurse about how you were treated last night." C. "I am glad you like me. Which nurse was acting aloof to you?" D. "What did the night nurse do that makes you think the nurse is aloof?"

Correct Answer is A

Explanation

A. "I am happy that you are getting better and will be able to go home."
This response focuses on the client’s progress and avoids engaging with their polarized views. It provides positive reinforcement and shifts the focus toward recovery.

B. "Tomorrow I will talk to that nurse about how you were treated last night."
This could escalate the situation and may inadvertently validate the client's idealization or devaluation of others, without fully understanding the dynamics.

C. "I am glad you like me. Which nurse was acting aloof to you?"
This response reinforces the client’s idealization of the current nurse, which could perpetuate dichotomous thinking.

D. "What did the night nurse do that makes you think the nurse is aloof?"
This invites the client to focus on negative perceptions of the night nurse, potentially escalating their emotional instability.

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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 health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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A client is being discharged home after being treated for heart failure (HF. Which instruction should the nurse include in this client's discharge teaching plan?

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.