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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Rationale:

Initiate use of the bed alarm: This alerts staff when the client attempts to get out of bed, enabling quick assistance. It is especially crucial for clients with unilateral weakness and impaired mobility after stroke. Early response helps prevent falls and related injuries.
Place all client belongings out of reach: Placing items out of reach encourages the client to stretch, reach, or attempt to get out of bed unsafely. Stroke patients may have limited strength and poor balance, making this dangerous. It increases the risk of injury and delays access to essential items.
Instruct the client to call before getting up: Teaching the client to seek assistance before attempting to ambulate minimizes the risk of unassisted movement. Stroke patients often have impaired coordination or weakness, increasing the risk of falling.
Provide a call button kept within reach: Keeping the call bell within the client’s reach promotes autonomy and timely communication with the care team. It enables the client to signal for help easily in case of urgent needs or sudden symptoms.
Place the client in a room near the elevator: A room near the elevator may expose the client to high traffic, noise, and stimulation, which can increase confusion or anxiety. For a stroke patient needing rest and monitoring, this environment is not ideal.
Complete a swallow study before giving anything by mouth: A bedside swallow evaluation identifies risk for aspiration, which is common in stroke clients with impaired speech and facial droop. Preventing oral intake until clearance protects against aspiration pneumonia and choking.

A. "Are you the type of person who shares your problems easily?" B. "What do you think is your primary goal to achieve this time?" C. "Would you like me to sit with you for a while?" D. "Have you experienced changes in your life recently?"

Correct Answer is C

Explanation

Rationale:

A. "Are you the type of person who shares your problems easily?": This question explores communication style but may feel invasive or irrelevant to someone in acute distress. It does not directly address the client’s current emotional needs or offer support.

B. "What do you think is your primary goal to achieve this time?": Goal setting is important during the planning phase of care, but clients in overwhelming anxiety may not be ready for structured thinking. This question may increase pressure and exacerbate anxiety.

C. "Would you like me to sit with you for a while?": This offers immediate emotional support and conveys presence, which helps build trust and reduce anxiety. It is a therapeutic approach that meets the client’s most urgent need for calm and reassurance.

D. "Have you experienced changes in your life recently?": Life changes may contribute to anxiety, but exploring them is appropriate after the client feels emotionally safe and stable. The initial priority is to establish a calming presence, not to probe background stressors.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Click to indicate which interventions promote client safety. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

Correct Answer is C

Explanation

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