The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

hypovolemic shock.

hemodilution.

excess fluid volume.

deficient fluid volume.

Answer and Explanation

The Correct Answer is C

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

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Correct Answer is C

Explanation

A. A document that the client signs indicating they wish to be an organ donor: This describes an organ donor card or organ donation consent form, not a living will. An organ donor card is a document indicating the individual's wish to donate organs after death to benefit others in need of organ transplants.

B. A medical order that outlines the client's wishes if cardiac or respiratory arrest occurs: This describes a do-not-resuscitate (DNR) order, which is a medical order indicating that the individual does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It is specific to resuscitation preferences and is different from a living will.

C. A witnessed legal document that describes the client's wishes regarding medical care if unable to speak: This is the correct description of a living will. A living will is a legal document that outlines a person's preferences regarding medical treatment and interventions in the event they become incapacitated and unable to communicate their wishes. It typically addresses preferences for life-sustaining treatments, such as mechanical ventilation, artificial nutrition and hydration, and other medical interventions.

D. A legal document that lists who gets the client's property & belongings before if they cannot communicate: This describes a last will and testament, which is a legal document that outlines how a person's property and assets should be distributed after their death. It does not address medical care preferences or interventions during the person's lifetime.

A. "How often do you punish him by giving him a time-out or by using physical discipline?" B. "Physical punishment is not the best way to modify a child's behavior." C. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body." D. "Constantly touching the genitals indicates a urinary tract infection in a toddler." E. "Give him a little time, and he'll grow out of it. He's just too young to understand right now."

Correct Answer is ["B","C","E"]

Explanation

A. "How often do you punish him by giving him a time-out or by using physical discipline?": This response focuses on the mother's disciplinary methods rather than addressing the child's behavior directly. It may come across as judgmental or critical of the mother's parenting approach and does not provide helpful guidance or support.

B. "Physical punishment is not the best way to modify a child's behavior.": This response is appropriate because it addresses the mother's concern about punishment for the child's behavior. It educates the mother about the ineffectiveness and potential harm of physical punishment in modifying behavior. Instead, positive reinforcement, redirection, and open communication are recommended strategies for guiding children's behavior.

C. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body.": This response normalizes the child's behavior of touching and playing with his genitals as part of natural childhood development. It reassures the mother that such behavior is common and not necessarily indicative of abnormality or misconduct. Education about normal childhood sexual development can alleviate parental concerns and promote understanding and acceptance.

D. "Constantly touching the genitals indicates a urinary tract infection in a toddler.": This response is incorrect and may unnecessarily alarm the mother. While frequent touching of the genitals could indicate discomfort or irritation associated with a urinary tract infection in a toddler, it is not the case for a 7-year-old child. Additionally, it is essential to avoid making medical diagnoses without proper assessment by a healthcare professional.

E. "Give him a little time, and he'll grow out of it. He's just too young to understand right now." This response acknowledges the child's developmental stage and suggests that the behavior is likely temporary and will naturally resolve as the child matures. It reassures the mother that the behavior is typical for a child of this age and may not require immediate intervention.

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The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

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Naxlex Comprehensive Predictor Exams

The nurse is addressing a client's questions after admission to the hospital. What is an accurate description of a living will?

Correct Answer is C

Explanation

The mother of a 7-year-old child is concerned that the child "touches and plays" with the genitals despite being punished for doing so. Which response should the nurse make to the mother? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","E"]

Explanation

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