The nurse continues to care for the client

Exhibits

Click to highlight the findings that indicate the client's condition is worsening. To deselect a finding, click on the finding again.

Day 3

1500:

The client has been participating in meals over the past 24 hr. The client still cuts meals into small bites and moving them around the plate, but caloric intake has increased. The client reports shortness of breath.

Physical Exam:

General: cachectic

Cardiovascular: S1, S1, 53

Respiratory: bilateral crackles

Skin: mild yellow hue to skin when blanched, lanugo to the face and back.

Extremities: 2+ bilateral lower extremity pitting edema

Potassium 3.0 mEq/L (3.5 to5 mEq/L)

Phosphorus 2.3 mg/dL (3 to 4.5 mg/dL

Magnesium 1.0 mg/dL (1.3 to 2.1 mg/dL)

Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL)

client reports shortness of breath

Cardiovascular: S1, S1, 53

Respiratory: bilateral crackles

Extremities: 2+ bilateral lower extremity pitting edema

Phosphorus 2.3 mg/dL (3 to 4.5 mg/dL

Magnesium 1.0 mg/dL (1.3 to 2.1 mg/dL)

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Client reports shortness of breath suggests potential fluid overload, cardiac dysfunction, or pulmonary complications. In clients with severe malnutrition and refeeding syndrome, fluid shifts can lead to pulmonary edema.

Cardiovascular: S1, S1, S3 indicates the development of an S3 heart sound, which is abnormal and may suggest volume overload or early heart failure. This is concerning, especially in a client with severe malnutrition and electrolyte imbalances.

Respiratory: bilateral crackles suggest fluid accumulation in the lungs, possibly due to cardiac dysfunction or refeeding syndrome. The presence of pulmonary congestion in a malnourished client is a serious finding.

Extremities: 2+ bilateral lower extremity pitting edema indicates worsening fluid retention, which may be due to hypoalbuminemia, cardiac dysfunction, or electrolyte imbalances from refeeding syndrome. This is a worsening sign compared to 1+ edema on admission.

Phosphorus 2.3 mg/dL (3 to 4.5 mg/dL) is low and suggests refeeding syndrome, a dangerous metabolic complication that occurs when nutrition is reintroduced too rapidly in malnourished clients. Severe hypophosphatemia can lead to cardiac arrhythmias, muscle weakness, and respiratory failure.

Magnesium 1.0 mg/dL (1.3 to 2.1 mg/dL) is low and can contribute to arrhythmias, muscle weakness, and neuromuscular dysfunction. Hypomagnesemia is a critical feature of refeeding syndrome and can worsen cardiac instability.

Potassium 3.0 mEq/L (3.5 to 5 mEq/L) is still low but improving from 2.8 mEq/L on admission. This does not indicate worsening but rather a gradual correction of hypokalemia.

Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) is slightly elevated, possibly due to dehydration or reduced renal function, but it is not the most critical indicator of deterioration compared to the fluid overload and electrolyte imbalances.

Mild yellow hue to skin, lanugo to the face and back are expected findings in anorexia nervosa and do not indicate worsening. These symptoms develop over time due to malnutrition and hormonal changes, but they do not necessarily worsen acutely.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A. Grandiosity. Clients experiencing mania often exhibit inflated self-esteem or a sense of superiority, believing they have exceptional abilities, wealth, or power. This exaggerated confidence is a hallmark symptom of bipolar mania.
B. Flight of ideas. Rapid, continuous speech with abrupt topic changes is common in mania. Clients may jump from one idea to another without logical connections, making their speech difficult to follow. This is known as flight of ideas and reflects their racing thoughts.
C. Spitting. While agitation and impulsivity are common in mania, spitting is not a specific or expected symptom. Clients may exhibit verbal aggression or inappropriate behaviors, but spitting is not a defining feature of mania.
D. Hyperactivity. Mania is characterized by excessive energy, restlessness, and an inability to stay still. Clients often engage in reckless behaviors, have decreased need for sleep, and struggle with impulse control, contributing to hyperactivity.
E. Withdrawal. Social withdrawal is more characteristic of depressive episodes rather than mania. In contrast, manic individuals are often highly sociable, intrusive, and overly talkative, sometimes to the point of disrupting social norms.

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

Explanation

Intravenous phentolamine should be administered because the client is experiencing a hypertensive crisis due to the interaction between phenelzine (a monoamine oxidase inhibitor [MAOI]) and over-the-counter decongestants. MAOIs can cause severe hypertension when taken with sympathomimetic agents (such as pseudoephedrine, commonly found in decongestants). Phentolamine is an alpha-adrenergic antagonist that rapidly lowers blood pressure in hypertensive emergencies.

Apply a cooling blanket to the client because the client’s temperature is dangerously high (39.6°C/103.2°F), which may indicate autonomic dysregulation or hyperthermia associated with hypertensive crisis. Active cooling measures are necessary to prevent complications such as seizures, organ damage, or stroke.

Oral benztropine is used to treat extrapyramidal symptoms from antipsychotic medications but is not relevant to this client’s condition.

Oral valbenazine is used to treat tardive dyskinesia, a side effect of dopamine-blocking medications, but this client is experiencing a hypertensive crisis, not movement disorders.

Intravenous diphenhydramine is used for allergic reactions or dystonic reactions but does not treat hypertensive crisis or hyperthermia.

Placing the client on suicide precautions is unnecessary in this scenario, as there is no indication of suicidal ideation or self-harm.

Checking the client’s absolute neutrophil count is relevant for clients taking clozapine (due to the risk of agranulocytosis) but is unrelated to this case of hypertensive crisis from an MAOI interaction.

Educating the client to increase their salt intake is appropriate for MAOI-induced orthostatic hypotension, but this client has severe hypertension, making this recommendation inappropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply).

Correct Answer is ["A","B","D"]

Explanation

Exhibits Complete the following sentence by using the list of options. The nurse should plan to administer dropdownanddropdown

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

Explanation

A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest." The nurse should identify that the client is at risk for which of the following?

A charge nurse is providing education to a group of newly licensed nurses about the rights of clients who are involuntarily admitted. Which of the following responses indicates understanding of the teaching?

A nurse is teaching the guardian of a school-age child who has autism spectrum disorder about a new prescription for risperidone. Which of the following statements by the guardian demonstrates an understanding of the teaching?

A nurse is caring for a client who has just learned that their partner has died by suicide. Which of the following actions should the nurse take first?

A nurse is assessing a client who reports using cocaine 1 hour ago. Which of the following findings should the nurse expect?

A nurse is caring for a client who has posttraumatic stress disorder (PTSD) after being physically assaulted. The client is unable to recall any details of the event. Which of the following defense mechanisms should the nurse recognize that the client is displaying?

A nurse is assessing a client who has delirium as a result of sepsis. Which of the following manifestations should the nurse expect? (Select all that apply).

A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?