Patient Data

Exhibits

Data is evaluated to determine possible condition and appropriate interventions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Choices:

Alcohol withdrawal: The client's tachycardia, low-grade fever, tremulousness, agitation, and recent cessation of alcohol use suggest early alcohol withdrawal. The presence of a 10-year drinking history and neurological symptoms also supports this condition.
Implement seizure precautions: Seizure risk increases in alcohol withdrawal, especially within 6–48 hours of last intake. Safety measures are essential to reduce harm from potential seizures during detoxification.
Infuse thiamine: Chronic alcohol use often causes thiamine deficiency, which can lead to Wernicke's encephalopathy. Thiamine should be administered before glucose to prevent neurologic complications.
Seizure activity: Monitoring for seizures is crucial as withdrawal-related seizures are a common and dangerous complication in alcohol-dependent clients undergoing detox.
Vital signs: Autonomic instability (e.g., elevated blood pressure and heart rate) occurs during withdrawal. Frequent monitoring can help detect progression to delirium tremens.

Rationale for Incorrect Choices:

Increased intracranial pressure: Although the client has a head laceration, there is no loss of consciousness, vomiting, or abnormal GCS, making ICP less likely as the primary concern at this stage.
Pneumonia: There is no productive cough, lung involvement, abnormal lung sounds, or elevated white blood cell count to indicate pneumonia.
Anaphylaxis: The client’s symptoms do not suggest an allergic reaction, there is no rash, airway involvement, or sudden hypotension.
Administer albuterol: This is used for bronchospasm or asthma. The client has no respiratory distress, wheezing, or bronchoconstriction signs requiring bronchodilators.
Call rapid response: The client is stable and alert, with no sudden life-threatening deterioration, so rapid response is not necessary.
Insert central venous pressure (CVP) monitor: CVP monitoring is invasive and reserved for critically ill patients needing fluid status evaluation, not indicated in early alcohol withdrawal.
White blood cells: WBC count is more relevant for infection monitoring, which is not currently the primary issue in this presentation.
Glasgow Coma Scale: Although helpful if neurological deterioration is suspected, the client is alert and interactive, making GCS unnecessary as a routine measure in this case.
Monitor intracranial pressure (ICP): There is no evidence of head trauma severity or neurological decline warranting ICP monitoring at this time.

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Correct Answer is A

Explanation

Rationale:

A. She is a gravida 6, para 5: A high parity (multiple previous births) stretches the uterus significantly over time, increasing the risk of uterine atony—a leading cause of postpartum hemorrhage due to the uterus failing to contract effectively.

B. She received butorphanol 2 mg IV during labor: Butorphanol is a narcotic analgesic and does not directly contribute to excessive postpartum bleeding or uterine atony in typical doses.

C. She is over 35 years of age: Advanced maternal age can increase some obstetric risks, but it is not as directly associated with postpartum hemorrhage as high parity.

D. The second stage of labor lasted 10 minutes: A short second stage may lead to perineal trauma, but it is less likely to cause excessive vaginal bleeding compared to uterine atony from high parity.

A. The client's need for pain medication should be determined. B. The impending signs of death should be documented. C. The client's status should be conveyed to the chaplain. D. The nurse manager should be updated on the client's status.

Correct Answer is A

Explanation

Rationale:

A. The client's need for pain medication should be determined: Ensuring comfort is the top priority in end-of-life care, especially for a client with a DNR order. Assessing and managing pain helps uphold dignity and minimize suffering during the dying process.

B. The impending signs of death should be documented: Documentation is essential for maintaining accurate medical records, but it is not the first priority. Ensuring the client is comfortable and free from pain takes precedence over recording observations.

C. The client's status should be conveyed to the chaplain: Spiritual support is important, but it should follow after the client’s physical needs—especially pain relief—are addressed. Involving the chaplain is helpful but not the most urgent intervention in this context.

D. The nurse manager should be updated on the client's status: Informing leadership may be necessary for planning purposes, but it does not directly benefit the client’s care in the moment. Addressing physical symptoms must come before administrative communication.

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Naxlex Comprehensive Predictor Exams

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

Correct Answer is A

Explanation

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

Correct Answer is A

Explanation

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care?