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Which client statements require follow-up teaching by the nurse? Select all that apply.

“This diagnosis means that I am crazy.”.

“Many people have the same response to a stressful situation as I am having right now.”.

“I will probably need to be on medication for the rest of my life.”.

“I can use holistic approaches like meditation to help my symptoms.”.

“I am at high risk for post-traumatic stress disorder because I have acute stress disorder.”.

“I can learn to manage my thoughts better through therapy.”.

Answer and Explanation

Correct Answer : A,C

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.

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Correct Answer is C

Explanation

Choice A rationale

Keeping the head of the bed raised 45 degrees is a common practice in intensive care units to prevent aspiration pneumonia. However, in the context of septic shock, this intervention is not the highest priority.

Choice B rationale

Assessing the warmth of the extremities can provide information about peripheral perfusion. Cold extremities may indicate poor perfusion, a common symptom in septic shock. However, this is not the most critical intervention in the management of septic shock.

Choice C rationale

Maintaining strict intake and output records is crucial in the management of septic shock. Fluid balance is a key component of sepsis management. Monitoring fluid balance helps ensure that the patient is adequately hydrated, which is essential for maintaining blood pressure and organ perfusion.

Choice D rationale

Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or has a history of diabetes. However, in the context of septic shock, this is not the highest priority.

Correct Answer is ["18"]

Explanation

Step 1 is to calculate the infusion rate. The prescription is for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline.

So, the calculation would be (900 units ÷ 25,000 units) × 500 mL = 18 mL/hr.

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Which client statements require follow-up teaching by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider has prescribed a sepsis protocol to be initiated.Which intervention should the nurse prioritize in the plan of care?

Correct Answer is C

Explanation

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver?

Correct Answer is ["18"]

Explanation

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