Page 2616 - Saunders Comprehensive Review For NCLEX-RN

are immobilized clients. Basic preventive measures include early ambulation, leg
elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf
compression. Keeping the client well hydrated is essential because dehydration
predisposes to clotting. A pillow under the knees may cause venous stasis. Heat
should not be applied without a primary health care provider’s prescription.
Test-Taking Strategy: Note the strategic word, most. Focus on the subject,
measures to prevent deep vein thrombosis and pulmonary emboli. Use basic
principles related to the care of the immobile client to answer this question.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Vascular disorders
Priority Concepts: Clinical Judgment; Clotting
Reference: Ignatavicius, Workman, Rebar (2018), p. 742.

938. Answer: 1

Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from
situational, developmental, or societal sources of stress. A person in this state is
temporarily unable to cope with or adapt to the stressor by using previous coping
mechanisms. The person who intervenes in this situation (the nurse) “takes over” for
the client (authority) who is not in control and devises a plan (action) to secure and
maintain the client’s safety. When this has occurred, the nurse works collaboratively
with the client (participates) in developing new coping and problem-solving
strategies.
Test-Taking Strategy: Note the strategic word, priority. A client who experiences a
suicidal crisis is in a state of acute disequilibrium. Remember that in a crisis an
authority figure must emerge to take action.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Suicide
Priority Concepts: Mood and Affect; Safety
Reference: Varcarolis (2017), pp. 367, 369.

939. Answer: 2

Rationale: The client with tuberculosis must have sputum cultures performed
every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client
may return to work when the results of three sputum cultures are negative, because
the client is considered noninfectious at that point. Options 1, 3, and 4 are not
reliable determinants of a noninfectious status.
Test-Taking Strategy: Focus on the subject, concepts related to tuberculosis.
Knowing that a positive tuberculin skin test never reverts to negative helps you
eliminate option 4. From the remaining options, think about the mode of

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