The nurse is caring for a client in the emergency department.

Exhibits

Edema

Blood pressure

Pain location

Respiratory rate

Urinary output amount

Answer and Explanation

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

A. Edema, noted as 2+ in the eyelids and hands with periorbital edema and jugular vein distention, is consistent with glomerulonephritis. Glomerulonephritis often causes fluid retention due to impaired glomerular filtration, leading to edema and jugular vein distention as the kidneys fail to excrete excess fluid. This aligns with the client’s elevated blood urea nitrogen (BUN) of 45 mg/dL and creatinine of 2.6 mg/dL, indicating renal dysfunction. Acute pyelonephritis, primarily an infectious process, typically does not cause significant edema unless complicated by severe systemic effects, which are not evident here.

B. Elevated blood pressure of 182/86 mm Hg is consistent with glomerulonephritis. Glomerulonephritis frequently leads to hypertension due to sodium and water retention from impaired renal function, activating the renin-angiotensin-aldosterone system. The client’s laboratory results showing renal impairment (elevated BUN and creatinine) support this. Acute pyelonephritis may cause transient blood pressure elevation due to pain or infection, but hypertension is less characteristic compared to glomerulonephritis.

C. Pain location, described as flank pain with painful urination, is consistent with acute pyelonephritis. Pyelonephritis typically presents with flank pain and dysuria due to bacterial infection of the renal pelvis, as supported by the client’s positive nitrite and leukocyte esterase in the urinalysis, indicating a urinary tract infection. The history of recent strep throat further suggests a possible post-infectious process, but glomerulonephritis typically presents with painless hematuria rather than localized flank pain.

D. Elevated respiratory rate of 26/min is consistent with glomerulonephritis. The client’s shortness of breath, bilateral crackles, and oxygen saturation of 90% suggest pulmonary edema, a complication of fluid overload from glomerulonephritis due to reduced glomerular filtration. This aligns with Maslow’s hierarchy of physiological needs, prioritizing oxygenation. Acute pyelonephritis does not typically cause respiratory distress unless sepsis develops, but the client’s stable heart rate (88/min) and absence of severe systemic signs make this less likely.

E. Decreased urinary output, reported as last urination yesterday afternoon with dark reddish-brown urine, is consistent with both acute pyelonephritis and glomerulonephritis. In pyelonephritis, reduced urine output and dark urine with blood (3+ on urinalysis) result from infection and inflammation causing hematuria. In glomerulonephritis, oliguria and dark reddish-brown urine (due to hematuria from glomerular damage) are common, supported by the client’s elevated BUN, creatinine, and turbid urine. Both conditions align with the client’s presentation, as reduced urine output reflects renal impairment in either case.

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Correct Answer is B

Explanation

Choice A reason: Hospice care is for terminally ill clients with a prognosis of six months or less, not Alzheimer’s disease, which is chronic and progressive. It does not address the partner’s need for temporary relief from caregiving responsibilities, making it an inappropriate referral.

Choice B reason: Respite care provides temporary relief for caregivers, allowing time for errands or rest. Alzheimer’s caregiving is demanding, increasing caregiver stress and burnout risk. Respite services support the partner’s well-being, enabling continued care while addressing the neurological demands of Alzheimer’s management.

Choice C reason: A home health aide assists with daily activities but does not provide the partner with personal time away. While helpful for ongoing care, it does not directly address the partner’s expressed need for breaks, making it less appropriate than respite care.

Choice D reason: A social worker can coordinate resources but does not directly provide caregiver relief. While they may suggest respite care, the partner’s immediate need for time away is best met by respite services, which offer direct, temporary caregiving support.

A. Approach the client from the front. B. Give detailed explanations. C. Avoid having a structured schedule. D. Remove clocks from the room.

Correct Answer is A

Explanation

Choice A reason: Approaching a client with dementia from the front reduces the risk of startling them, as disorientation impairs spatial awareness. This approach promotes safety and trust, allowing the client to see the nurse clearly, which can decrease agitation and confusion commonly associated with dementia’s cognitive deficits.

Choice B reason: Detailed explanations can overwhelm clients with dementia due to impaired cognitive processing and memory deficits. Simplified, concise communication is more effective, as complex information may increase confusion or anxiety, exacerbating disorientation and reducing the client’s ability to engage with care effectively.

Choice C reason: A structured schedule is beneficial for clients with dementia, as it provides predictability, reducing anxiety and disorientation. Avoiding a routine can worsen confusion by disrupting familiar patterns, which are critical for maintaining cognitive stability in clients with progressive neurodegenerative conditions like dementia.

Choice D reason: Removing clocks can increase disorientation in dementia clients, as visual cues like time help anchor them to reality. Clocks support temporal orientation, reducing confusion and agitation. Their presence is a non-pharmacological strategy to enhance cognitive grounding in clients with memory and processing deficits.

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The nurse is caring for a client in the emergency department. Exhibits

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Naxlex Comprehensive Predictor Exams

A nurse is performing a home visit on a client who has Alzheimer’s disease and their partner. The partner states, “I wish I had some time to myself and run errands, but I need to be here all the time.” Which of the following referrals should the nurse recommend to the client’s partner?

Correct Answer is B

Explanation

A nurse is caring for a client who has dementia and is experiencing disorientation. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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The nurse is caring for a client in the emergency department.

Exhibits