The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.

Complete the following sentence by using the lists of options.

The client is most at risk for

due to

.

Answer and Explanation

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

seizures: If a thyroid storm occurs, the client can experience seizures due to the extreme metabolic disturbances and nervous system overstimulation it causes. Seizures would be a serious complication indicating worsening neurological function. Therefore, the client’s risk for seizures is directly related to the risk of developing a thyroid storm after surgery.
paralytic ileus: Paralytic ileus involves bowel inactivity post-surgery, but the client had normoactive bowel sounds before surgery and no current documentation of absent or significantly reduced bowel activity. Therefore, this is not the most immediate risk based on current findings.
pneumonia: The client is receiving oxygen therapy and has a slightly increased respiratory rate after surgery, but no signs of labored breathing, abnormal lung sounds, or infection are reported. Although inactivity can contribute to pneumonia risk postoperatively, there are no current findings indicating that pneumonia is developing right now.
thyroid storm: The client had a thyroidectomy after presenting with signs of severe hyperthyroidism (weight loss, heat intolerance, anxiety, exophthalmos, goiter) and elevated T3 and T4 levels. Thyroid storm is a critical risk after thyroidectomy due to sudden hormone release, and it can cause life-threatening complications such as high fever, hypertension, tachycardia, and altered mental status.
bowel sounds: The bowel sounds were normal before surgery, and there is no mention of significant gastrointestinal changes postoperatively. Bowel sounds alone are not the critical factor leading to the client’s highest current risk.
inactivity: The client is currently lethargic after surgery and under the effects of anesthesia, which reduces movement and activity. Inactivity can cause decreased lung expansion and increase the risk of pulmonary complications like pneumonia. Although this is a concern, inactivity is not the client's most critical immediate risk compared to thyroid storm.

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Correct Answer is C

Explanation

A. Limit periods of sitting in a chair to 4 hr: Clients with urinary incontinence should avoid prolonged sitting because it increases pressure on the skin and raises the risk of skin breakdown. Sitting should be limited to shorter periods with frequent repositioning to protect skin integrity.

B. Avoid the use of draw sheets for repositioning: Draw sheets are helpful for repositioning clients safely and reducing friction and shear forces on the skin. Avoiding their use would increase the risk of skin injury, especially in clients with incontinence who are already vulnerable.

C. Use a no-rinse perineal cleanser after incontinence: Using a no-rinse perineal cleanser helps maintain skin hygiene, removes urine and feces gently, and prevents irritation or breakdown. It is an important part of incontinence care to protect the client's skin health.

D. Keep the head of the client's bed elevated to 45º: Elevating the head of the bed to 45º degrees is helpful for respiratory support but does not directly address urinary incontinence. Bed positioning should be adjusted based on overall client needs, not specifically to manage incontinence.

A. A client who has hearing loss with a friend interpreting B. A client who has not spoken with the provider yet C. A 15-year-old client whose caregiver is not at the bedside. D. A married 16-year-old client accompanied by their spouse

Correct Answer is D

Explanation

A. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.

B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.

C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.

D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

Correct Answer is D

Explanation

A nurse is reinforcing teaching for a client who has a new sigmoid colostomy. Which of the following comments by the client indicates an understanding of the teaching?

A nurse is assisting in the care of a client suspected of having a tuberculosis infection. Which of the following personal protective equipment should the nurse wear when in the client's room?

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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (APIT

A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is monitoring a young adult client for risk-taking behavior. Which of the following statements by the client indicates they are limiting their risk-taking behavior?

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.

Complete the following sentence by using the lists of options.

The client is most at risk for

due to

.