The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks.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can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.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reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.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 C

Explanation

The correct answer is: c. Inspiratory and expiratory bilateral crackles.

Choice A: Average urine output of 28 mL/hour

Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.

Choice B: Vesicular bibasilar breath sounds

Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.

Choice C: Inspiratory and expiratory bilateral crackles

Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.

Choice D: Central venous pressure of 12 mm Hg

Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.

A. Were your legs ever suddenly swollen, red, warm, and painful? B. Did you receive treatment for weeping ulcers on lower legs? C. Have you experienced ankle edema and varicose veins? D. Does the calf pain occur when walking short distances?

Correct Answer is D

Explanation

Choice A reason: Sudden swelling, redness, warmth, and pain are more indicative of acute conditions like deep vein thrombosis rather than chronic arterial symptoms.

Choice B reason: Weeping ulcers on lower legs are more commonly associated with venous insufficiency rather than arterial disease.

Choice C reason: Ankle edema and varicose veins are typically associated with venous disorders, not arterial disease.

Choice D reason: Intermittent claudication, which is pain during walking that subsides with rest, is a hallmark of peripheral arterial disease and is an expected finding in clients with this condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

A client arrives for an annual physical exam and reports having calf pain. The client's health history includes peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

Correct Answer is D

Explanation

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