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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Presence of cough

Absence of gag reflex

Respiratory rate of 6 breaths per minute

Urine output 90 mL/hour

Heart rate 70 beats per minute

Capillary refill less than 3 seconds

Answer and Explanation

Correct Answer : B,C

A. The presence of a cough is expected as a protective reflex and does not delay transfer.

B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.

C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.

D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.

E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.

F. Capillary refill less than 3 seconds is normal and does not delay the transfer.

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Correct Answer is A

Explanation

A. The client’s physical symptoms (chest pain, headache, shortness of breath) and statements about not understanding why his wife left indicate a panic level of anxiety, which is marked by intense physical and emotional distress.

B. Moderate anxiety involves increased nervousness or slight discomfort but does not cause the severe physical symptoms seen in panic anxiety.

C. Mild anxiety presents with slight restlessness or tension, without significant physical symptoms.

D. Severe anxiety would involve significant impairment in thinking or perception but is more focused on a sense of being overwhelmed or immobilized, rather than exhibiting full panic symptoms.

A. Binge eating and weight gain B. Nightmares, difficulty concentrating, and irritability C. Purging the last meal D. Decreased energy and fatigue

Correct Answer is B

Explanation

A. Binge eating and weight gain are more commonly associated with eating disorders or other psychological conditions, not PTSD.

B. Nightmares, difficulty concentrating, and irritability are key symptoms of PTSD, reflecting the psychological impact of trauma. These are consistent with the intrusive and arousal symptoms associated with PTSD.

C. Purging is associated with eating disorders, not PTSD.

D. Decreased energy and fatigue are common symptoms of depression, not specifically indicative of PTSD, although they can be seen in both conditions.

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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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