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: This statement reflects denial or confusion, not displacement. Denial involves rejecting reality, often seen in personality disorders, but displacement specifically involves redirecting emotions to a less threatening target. This statement does not indicate redirecting feelings from one source to another.

Choice B reason: Displacement involves redirecting emotions from the true source to a safer target. Blaming the night shift nurse suggests the client is projecting anger or frustration, possibly intended for another source (e.g., family or self), onto the nurse, a common maladaptive mechanism in personality disorders.

Choice C reason: This statement reflects magical thinking or bargaining, not displacement. It suggests a belief that compliance will resolve the issue, often seen in anxiety or obsessive-compulsive disorders. Displacement involves emotional redirection, not conditional thinking about problem resolution.

Choice D reason: Expressing anger directly toward the spouse indicates direct expression, not displacement. Displacement involves redirecting emotions to a substitute target, not the original source of the emotion, making this statement an example of direct aggression rather than a maladaptive defense mechanism.

A. Clients who have a severe mental illness cannot request a psychiatric advance directive. B. Client withdrawal of prior consent must be done in writing. C. Clients who are involuntarily committed do not maintain access to legal counsel. D. Clients can refuse to attend group therapy.

Correct Answer is D

Explanation

Choice A reason: Clients with severe mental illness can request psychiatric advance directives if they have decision-making capacity. These directives outline treatment preferences, supporting autonomy despite cognitive impairments, making this statement incorrect for client rights education.

Choice B reason: Withdrawal of consent does not always require writing; verbal withdrawal is valid in many settings. Mental health clients retain autonomy to revoke consent, and policies prioritize flexibility to respect their rights, making this an inaccurate statement for the in-service.

Choice C reason: Involuntarily committed clients retain access to legal counsel to protect their rights. This ensures due process, as involuntary commitment involves legal oversight. Denying counsel violates ethical and legal standards, making this incorrect for client rights education.

Choice D reason: Clients can refuse group therapy, as autonomy allows refusal of non-emergency treatments. This right is protected unless the client poses an immediate risk, aligning with ethical principles of self-determination in mental health care, making this correct for the in-service.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a personality disorder. Which of the following statements made by the client indicates they are coping with the maladaptive defense mechanism of displacement?

Correct Answer is B

Explanation

A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

A nurse is assisting a provider in obtaining informed consent from a client who has depressive disorder and is scheduled to have electroconvulsive therapy (ECT). The signature of the nurse on the consent form indicates which of the following?

A nurse is reviewing the medical records for a group of clients prior to administering the clients’ medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicates an understanding of the teaching?

A nurse is assessing a client who has Alzheimer’s disease. Which of the following findings should the nurse identify as the priority?

A nurse is caring for a client who has a substance use disorder. The client states, “The state took my child away after my overdose. I don’t want to go on living without them.” Which of the following therapeutic responses should the nurse make?

A nurse is caring for a client who was agitated during group therapy and unable to be redirected. Which of the following actions should the nurse implement first?

A nurse on a mental health unit is preparing an in-service about ethical concepts when providing client care. Which of the following definitions should the nurse include when discussing advocacy?

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

Exhibits