Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

Fatigue

Generalized weakness

Muscle cramps

Tingling sensation in her arms and legs

Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

Blood Pressure: 146/82 mmHg

Heart Rate: 114 bpm

Respiratory Rate: 18 bpm

SpO₂: 98% on room air

Temperature: 98.2 °F (36.8 °C) orally

Muscle cramps

Tingling sensation in her arms and legs

Lightheadedness

Fatigue

68-year-old with a history of diabetes, hypertension

Blood Pressure: 146/82 mmHg

Heart Rate: 114 bpm

Temperature: 98.2 °F

Answer and Explanation

The Correct Answer is ["A","B","C"]

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

Defense Mechanism: Fantasy

Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.

B. The client seems unemotional when talking about needing to rebuild her house.

Defense Mechanism: Isolation

Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.

C. The client states that she sometimes forgets why she is in the hospital.

Defense Mechanism: Suppression

Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.

D. The client is frightened that the hospital will burn down.

Defense Mechanism: Denial

Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.

Summary of Answers:

A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
C. Suppression - The client states that she sometimes forgets why she is in the hospital.
D. Denial - The client is frightened that the hospital will burn down.

A. Encourage the mother to write thoughts and feelings in a journal. B. Determine if the mother has other children who do not have developmental disabilities. C. Reassure the mother that her child will achieve some growth and development milestones. D. Ask the mother if she has ever thought about harming herself or her child.

Correct Answer is A

Explanation

Choice A rationale:
Encouraging the mother to write her thoughts and feelings in a journal is a constructive and therapeutic response. It provides an outlet for the mother to express her emotions and can be a helpful tool for coping with the challenges she is facing.

Choice B rationale:
Determining if the mother has other children who do not have developmental disabilities may be relevant to understanding her support system and family dynamics, but it does not directly address her current emotional distress.

Choice C rationale:
Reassuring the mother that her child will achieve some growth and development milestones may not be appropriate in this situation, as the child's disabilities are described as profound, and it is uncertain what milestones the child will reach. Providing false hope may not be helpful and could be misleading.

Choice D rationale:
Asking the mother if she has ever thought about harming herself or her child is an important inquiry related to her emotional state and the potential risk of harm. However, it should follow the initial response of encouraging her to express her thoughts and feelings in a journal.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

B. The client seems unemotional when talking about needing to rebuild her house.

C. The client states that she sometimes forgets why she is in the hospital.

D. The client is frightened that the hospital will burn down.

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Correct Answer is A

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)