The Theory-Guided Practice: Describe a middle-range nursing theory and discuss
NGN MOCK EXAM 94. This is a Stand-Alone Trend item that presents clinical information over * 1 point time. Review information at all time points presented looking for upward and downward trends. Determine what the trend means for the client. Specifically, this is a Drop-Down Cloze question. Complete the sentence or fill-in-the-blank by choosing from a list of drop-down options and selecting the correct option. The nurse reviews the medical record of a 54-year-old client admitted with a blood alcohol concentration (BAC) of 0.24% (serum ethanol level of 240 mg/dL [52. 1 mmol/LD). Notes 0330: Admitted to ED accompanied by children who state the client has been drinking every night since the spouse died last year from breast cancer. Medical history includes Stage 2 chronic kidney disease and hypertension. Client disoriented, has an ataxic gait, and is extremely drowsy. Speech slurred; Irritable and disoriented. IV of 5% D/D.45 NS Initiated. 0430: Very drowsy, disoriented, increasingly irritable with slight hand tremors, Vomited 100 mL clear greenish yellow liquid. 0530: Becoming more agitated and yelling at staff. Disoriented and drowsy; speech continues to be slurred. Hand tremors worsening. Vomited 75 mL clear greenish liquid; obtained order for ondansetron and administered x 1. Has not voided since admission Flow Sheet an’s Order Lab Tests Vital Signs 0330 (Admission) 0430 0530 T (forehead) 96.8 F (36. C) 96 80 F (36. C) 97.20 F (36.2. C) HR 62 BPM 64 BPM 64 BPM RR 14 bom 14 bom 16 bom BP 100/58 mmHg 102/54 mmHg 106/58 mmHg Complete the following sentence by selecting from the lists of options below. The priority nursing action is to monitor the client for(]- which are commonly associated with 1st set of answers 2nd set of answers 3rd set of answers seizures seizures -schizophrenia delusions delusions -fluid and electrolyte nystagmus nystagmus imbalance hallucination hallucination -alcohol withdrawal delirium -Wernicke’s encephalopathy O A: Delusions and hallucinations which are commonly associated with alcohol withdrawal delirium. B: Seizures and hallucinations which are commonly associated with schizophrenia. O C: Hallucinations and seizures which are commonly associated with fluid and electrolyte imbalance. O D: Nystagmus and delusions which are commonly associated with Wernicke’s encephalopathy. E: Delusions and hallucinations which are commonly associated with schizophrenia.
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