Which client statement or behavior is most likely associated with their current condition?

The client discusses moving to Hawaii.

The client seems unemotional when talking about needing to rebuild her house.

The client expresses a desire to be in a quieter area of the unit.

The client requests sleeping medication for the night.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.

Choice B rationale

Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.

Choice C rationale

Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.

Choice D rationale

Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.

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Correct Answer is A

Explanation

Choice A rationale

Observing for signs of depression is the most important intervention for the nurse to include in the client’s plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client’s overall well-being and successful outcomes.

A. Change the surgical dressing promptly when it becomes soiled. B. Monitor for any increase in the white blood cell count. C. Educate the family on the importance of adhering to contact precautions. D. Always wear a face mask while performing wound care.

Correct Answer is A

Explanation

Choice A rationale

Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.

Choice B rationale

Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice C rationale

Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice D rationale

Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

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Which client statement or behavior is most likely associated with their current condition?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

Correct Answer is A

Explanation

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