Nokea
Fill in the blanks with one condition and one client finding.The client is most likely experiencing---------- as evidenced by the client's--------
- A. Mania
- B. Delirium
- C. Catatonia
- D. Magical thinking
- E. Euphoric mood
- F. Hypervigilance
- G. Panic disorder
Correct Answer: A,E
Rationale: The correct answer is A, E. Mania is characterized by elevated mood, increased energy levels, and impulsivity. The client is most likely experiencing mania as evidenced by euphoric mood. Euphoric mood is a key symptom of mania, reflecting a heightened sense of well-being and happiness. Therefore, the combination of mania and euphoric mood is indicative of a manic episode. Choices B, C, D, F, and G are incorrect as they do not align with the symptoms and presentation of mania. Delirium is characterized by confusion and disorientation, not euphoric mood. Catatonia involves motor disturbances, not euphoric mood. Magical thinking refers to unrealistic beliefs, not necessarily elevated mood. Hypervigilance is associated with anxiety disorders, not mania. Panic disorder is characterized by recurrent panic attacks, not euphoric mood.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Anticipate administering prescribed immunosuppressant medications
- B. Ensure that client has intake of at least 200 ml/hr
- C. Encourage client to avoid direst sunlight
- D. Initiate contact precautions
- E. Prepare client for light therapy
- F. Sickle cell crisis
- G. Psoriasis
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.
Which of the following actions should the nurse plan to take?
- A. Elevate the clients arm prior to insertion.
- B. Select a site on the client's dominant arm.
- C. Apply a tourniquet below the venipuncture site.
- D. Choose a vein that is palpable and straight.
Correct Answer: D
Rationale: The correct answer is D: Choose a vein that is palpable and straight. This is important because a palpable and straight vein ensures successful venipuncture and reduces the risk of complications such as infiltration or hematoma formation. Elevating the client's arm (A) may help visualize veins but does not guarantee choosing a suitable vein. Selecting a site on the client's dominant arm (B) is not necessary as both arms have suitable veins. Applying a tourniquet below the venipuncture site (C) can obstruct blood flow and distort the vein. Therefore, the best approach is to choose a vein that is palpable and straight for a successful venipuncture.
The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.
- A. The client engages in quiet activities in their room
- B. The client slept 5 hr. the previous night
- C. The client consumes 8 oz of high-calorie fluids each hour
- D. The client takes 2 short naps during the day
- E. The client appears to listen to unseen others.
Correct Answer: A,B,C,D
Rationale: Improved behaviors include engaging in quiet activities, sleeping adequately, consuming fluids, and napping appropriately. Listening to unseen others indicates ongoing psychosis.
Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.
Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 mL.
- B. The client has a good appetite and ate well before surgery.
- C. The client's family visited during the recovery period.
- D. The client's call light is within reach.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 mL. This statement is important for the receiving nurse to know as it provides crucial information about the client's condition post-surgery. It helps in monitoring for signs of hemorrhage or other complications. The other choices (B, C, D) are not essential for the hand-off report as they do not directly impact the client's immediate care or safety. Choice B is subjective and not a clinical observation. Choice C is about the client's family, which is not pertinent to the client's medical status. Choice D is a general safety measure and not specific to the client's condition.