The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.
Complete the following sentence by using the list of options.
The nurse should first plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale:
• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.
• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.
• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.
• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.
• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.
• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","G","H"]
Explanation
Rationale:
• Urinary stasis: Immobility slows bladder emptying and ureteral flow, increasing residual urine. This promotes bacterial growth and risk of urinary tract infection. MS clients with decreased mobility are especially vulnerable.
• Calcium resorption: Bone demineralization occurs during prolonged immobility. Without weight-bearing, calcium is released from bone into the bloodstream, raising serum calcium and weakening bones.
• Contractures: Lack of movement leads to shortening and stiffening of muscles and joints. Over time, joints lose flexibility, especially if the client remains curled in one position.
• Hypocalcemia: The client is more likely to develop hypercalcemia due to calcium resorption from bones. There's no evidence of low calcium symptoms like tetany or numbness.
• Hypertension: The client's vital signs are within normal range. Immobility may reduce cardiac output over time, but it does not typically cause high blood pressure.
• Diarrhea: Immobility usually causes constipation due to slowed peristalsis. There's no report of active GI symptoms or triggers for diarrhea in this case.
• Pressure ulcer: Continuous pressure on one area reduces capillary blood flow. This leads to tissue ischemia and skin breakdown, especially over bony prominences like the hip and shoulder.
• Atelectasis: Lying on one side restricts lung expansion, and refusal to change positions impairs ventilation. This can cause alveolar collapse and decreased oxygen exchange.
Correct Answer is C
Explanation
Rationale:
A. “I should try to focus on pleasant images to help replace stressful and negative feelings I have.”: This describes guided imagery, a relaxation technique that uses visualization to reduce stress. While helpful, it does not involve the cognitive restructuring.
B. “I will use my smartwatch to monitor my sleep and heart rate to assist me with gaining voluntary control over my stress.”: This reflects biofeedback, where physiological responses are tracked and managed through conscious control. It involves physical awareness, not cognitive reinterpretation of stress.
C. "I should reassess the situation and change my perceptions of stress by replacing irrational beliefs.”: This is cognitive reframing, a technique that helps clients identify and challenge distorted thinking and replace it with more rational, constructive thoughts to alter their emotional responses to stress.
D. "I will tense my muscles for 8 seconds and then relax them to release the tension caused by my stress.”: This refers to progressive muscle relaxation, which targets physical symptoms of stress rather than the cognitive processes addressed in cognitive reframing.
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