Nokea
Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.
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The client has been violent toward other clients on a mental health unit and interventions have failed. During the application of restraints which action by the team leader will gain the greatest cooperation from the client?
- A. Showing sympathy by apologizing for the need to restrain the client
- B. Dispassionately explaining why and how the restraints will be applied
- C. Affording the client one last opportunity to avoid restraints by “behaving”
- D. Offering to remove the restraints as soon as the client can “control the anger”
Correct Answer: B
Rationale: Explaining why and how restraints are applied (B) reduces resistance. Apologizing (A) implies mistreatment negotiating (C) undermines the decision and promising removal (D) is ineffective.
Which nursing action is the highest priority during the immediate care of a rape victim?
- A. Documenting the circumstances of the rape
- B. Keeping contact with strangers to a minimum
- C. Offering the victim a choice of sedatives
- D. Providing a bath basin, gown, towel, and washcloth
Correct Answer: B
Rationale: Minimizing contact with strangers protects the victim's privacy and reduces distress, prioritizing emotional safety in the immediate aftermath.
The 19-year old client regularly abuses dextromethorphan (DXM). Which activity if performed under the influence of dextromethorphan places the client at highest risk for complications related to DXM abuse?
- A. Dancing at a nightclub
- B. Competing in a swim meet
- C. Snow-skiing on spring break
- D. Fishing from a shaded shoreline
Correct Answer: A
Rationale: Dancing (A) risks hyperthermia with DXM. Swimming (B) skiing (C) and fishing (D) are cooler lower-risk activities.
The hospitalized client has a history of weekly moderate alcohol use. Which symptoms assessed by the nurse indicate that the client may be experiencing alcohol withdrawal? Select all that apply.
- A. Agitation
- B. Hypotension
- C. Tachycardia
- D. Hallucinations
- E. Tongue tremor
Correct Answer: A, C ,D ,E
Rationale: Withdrawal causes agitation (A) tachycardia (C) hallucinations (D) and tongue tremor (E) via NMDA receptor activity. Hypotension (B) is incorrect; hypertension occurs.
The nurse is assessing the college student who presents with generalized fatigue dry mouth tachycardia and an increased appetite. Which additional finding from the client’s history and physical exam should alert the nurse to explore possible marijuana abuse?
- A. Paranoia
- B. Flashbacks
- C. Gastric disturbances
- D. Conjunctival infection
Correct Answer: D
Rationale: Conjunctival infection (D) is a marijuana sign with fatigue dry mouth tachycardia and appetite increase. Paranoia (A) is methamphetamine flashbacks (B) are hallucinogens gastric issues (C) are alcohol.