The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Engage the client in non-threatening conversations.

Encourage the client's family to visit more often.

Schedule a daily conference with the social worker.

Encourage the client to participate in group activities.

Answer and Explanation

The Correct Answer is A

Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.

Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.

Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.

Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.

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Correct Answer is B

Explanation

Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.

Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.

Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.

A. Sloughing tissue around wound edges. B. Loss of sensation to the left lower extremity. C. Weeping serosanguineous fluid from wounds. D. Reporting increased pain and pressure. E. Change in the quality of the peripheral pulses.

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

Explanation

Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.

Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.

Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.

Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.

Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

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The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

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

Explanation

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply.

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Patient Data Exhibits After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents.