Patient Data

The nurse evaluates the client, vital signs, and laboratory results.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is at the highest risk for
dropdown
as a result of
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale:

• Hepatitis: The client’s elevated liver enzymes (AST 48 U/L, ALT 59 U/L), elevated bilirubin (3 mg/dL), and clinical signs such as jaundice and spider angiomas indicate liver inflammation and damage. These findings are consistent with alcoholic hepatitis, a condition caused by chronic alcohol consumption. The combination of laboratory abnormalities and physical assessment strongly supports hepatitis as the primary risk.

• Nephritis: There is no evidence of renal inflammation in the assessment. The client’s genitourinary function is within normal limits, and there are no laboratory findings suggesting elevated creatinine or hematuria.

• Cholecystitis: Although the client has jaundice, there is no reported right upper quadrant pain, fever, or Murphy’s sign, which are typical for gallbladder inflammation. Abdominal distension is more likely related to liver disease or ascites rather than cholecystitis.

• Chronic alcohol abuse: The client reports long-term, heavy alcohol use (12–16 beers daily for 2 years), which is the leading cause of hepatocellular injury in adults. Chronic alcohol intake disrupts liver metabolism, causes fat accumulation in hepatocytes, and increases the risk of alcoholic hepatitis, fibrosis, and cirrhosis. This risk factor directly explains the lab and clinical findings, making it the most relevant cause.

• Unmanaged hypertension: While the client has a history of untreated hypertension, it does not explain the elevated liver enzymes or jaundice. Hypertension increases cardiovascular risk but is not the primary factor causing hepatic injury.

• Viral infection: Viral hepatitis could cause similar laboratory and clinical findings, but there is no evidence of recent viral illness or laboratory confirmation. Chronic alcohol abuse is a more consistent explanation for the constellation of findings in this client.

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Correct Answer is A

Explanation

Rationale:
A. History of vomiting at home for 3 days prior to surgery: A recent history of prolonged vomiting increases the risk of dehydration, electrolyte imbalances, and delayed gastric emptying. This information is crucial for the receiving nurse to consider when monitoring fluid status, nausea, and postoperative recovery, making it essential to report.

B. Soft abdomen, absent bowel sounds, no bleeding on dressing: These findings are expected immediately after abdominal surgery and are routine for PACU handoff. While important to note, they do not represent additional risk factors requiring urgent attention.

C. Declining to take ice chips despite reporting of dry mouth: While oral intake may help with comfort, refusal of ice chips is not an urgent clinical concern. It can be addressed post-transfer once safety and vital signs are assessed.

D. Peripheral pulses present with full range of motion of both legs: Normal peripheral neurovascular findings are expected and routine for PACU report. This information does not require immediate additional attention.

A. Explain to the parents that anger is a common response to grief. B. Refer the parents to the chaplain to provide grief counseling. C. Assure the parents that a terminal diagnosis was inevitable. D. Tell the parents that blaming each other will not change the situation.

Correct Answer is A

Explanation

Rationale:
A. Explain to the parents that anger is a common response to grief: Anger is a normal stage of grief and often occurs when families are processing shock, fear, and helplessness after a terminal diagnosis. Providing education and normalization helps reduce guilt, facilitates emotional expression, and supports healthy coping.

B. Refer the parents to the chaplain to provide grief counseling: Chaplaincy support can be helpful for spiritual and emotional needs, but immediate intervention involves addressing the parents’ acute emotional response. Referral alone does not provide timely support for the anger being expressed.

C. Assure the parents that a terminal diagnosis was inevitable: Telling parents the outcome was inevitable may be perceived as dismissive or minimizing their feelings. It does not validate their emotions or help them process grief constructively.

D. Tell the parents that blaming each other will not change the situation: Confronting blame without acknowledging emotions may increase defensiveness and conflict. Immediate support should focus on understanding and normalizing grief reactions rather than correcting behavior.

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Patient Data The nurse evaluates the client, vital signs, and laboratory results. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is at the highest risk for dropdown as a result of dropdown.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?

Correct Answer is A

Explanation

The nurse reviews the information from the initial assessment and history and physical. Which 6 findings in the client's history should the nurse recognize as risk factors for a cerebrovascular event?

Patient Data For each nursing intervention, click to indicate whether the action is appropriate or not appropriate for this client. Each row must have only one response option selected.

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

Patient Data Based on the client’s history and assessment findings, which of the following are priority nursing concerns for this client? Select all that apply.

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions?

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

The nurse is assessing a client who is reporting a severe headache. During the physical assessment, which finding should the nurse interpret as a possible indication of meningitis?

Patient Data

The nurse evaluates the client, vital signs, and laboratory results.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is at the highest risk for
dropdown
as a result of
dropdown
.