When caring for a client with severe dehydration, the nurse should ensure which results are documented?

Catheter care

Oxygen saturation

Respiratory rate

Intake/output

Answer and Explanation

The Correct Answer is C

Choice A reason: Catheter care is procedural, not a physiological result reflecting dehydration status. While catheters may be used, documenting care does not directly monitor the effects of severe dehydration, like fluid balance or respiratory changes, making this choice incorrect.

Choice B reason: Oxygen saturation may be normal in dehydration unless complicated by other conditions. It is not a primary indicator of dehydration, which primarily affects fluid volume and electrolytes, making it less critical than respiratory rate and intake/output.

Choice C reason: Respiratory rate is a critical result in severe dehydration, as compensatory hyperventilation may occur to correct acid-base imbalances like metabolic acidosis from hypoperfusion. Documenting this monitors the body’s response to fluid loss, making this a correct choice.

Choice D reason: Intake/output is essential in severe dehydration to track fluid balance. Accurate documentation of fluid intake and urine output assesses rehydration effectiveness and kidney function, critical for managing dehydration, making this a correct choice.

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Correct Answer is B

Explanation

Choice A reason: A semi-private room near the day room is noisy and stimulating, which can exacerbate manic symptoms like agitation and impulsivity. A calm environment is needed, making this choice inappropriate for a manic client.

Choice B reason: A private room in a quiet location minimizes sensory stimulation, reducing agitation and impulsivity in the manic phase of bipolar disorder. This promotes safety and stabilization, aligning with therapeutic needs, making this the correct choice.

Choice C reason: A private room near the exercise room may increase stimulation due to activity and noise, worsening manic symptoms. A quiet environment is critical for de-escalation, making this choice less suitable than a quiet location.

Choice D reason: A semi-private room near the snack area risks overstimulation and social conflicts during a manic phase. Sharing a room and proximity to activity are inappropriate, making this choice incorrect for managing mania.

A. I am just so sad. I cannot believe that my partner is gone B. I just cannot remember anything about the accident C. I don’t want to think or talk about what happened with anyone D. If I wasn’t such a bad person, this never would have happened

Correct Answer is C

Explanation

Choice A reason: Expressing sadness about the partner’s death reflects grief, not avoidance. Avoidance involves actively suppressing thoughts or discussions about the trauma. This statement indicates emotional processing, not avoidance, making it incorrect for identifying avoidance symptoms in this context.

Choice B reason: Inability to recall the accident may suggest dissociative amnesia, a potential trauma response, but it is not a clear avoidance symptom. Avoidance involves conscious efforts to avoid trauma-related stimuli, not memory loss, making this choice less precise than active refusal to discuss.

Choice C reason: Refusing to think or talk about the accident is a hallmark of avoidance symptoms in post-traumatic stress disorder (PTSD). This behavior reflects deliberate efforts to suppress trauma-related thoughts or conversations to reduce distress, aligning with the scenario, making this the correct choice.

Choice D reason: Blaming oneself for the accident reflects guilt or negative self-perception, common in PTSD, but is not an avoidance symptom. Avoidance involves dodging trauma-related stimuli, not internalizing blame, making this choice incorrect for identifying avoidance behaviors.

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When caring for a client with severe dehydration, the nurse should ensure which results are documented?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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