Nokea
The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.
- A. I am currently unemployed and looking for a job
- B. I have been married for five years with three children
- C. I have multiple firearms at home stored in a safe
- D. I have been about a year since I last overdosed
- E. I attend weekly religious activities with my family
- F. Sometimes I experience feelings of hopelessness
Correct Answer: A,C,D,F
Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.
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The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?
- A. Gum bleeding
- B. Lung sounds
- C. Homan's sign
- D. Generalized weakness
Correct Answer: A
Rationale: The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.
The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose?
- A. To lower the blood alcohol level
- B. To prevent gross tremors
- C. To prevent Wernicke encephalopathy
- D. To treat seizures related to acute alcohol withdrawal
Correct Answer: C
Rationale: Thiamine prevents Wernicke encephalopathy, a neurological disorder from thiamine deficiency common in chronic alcoholism. It does not lower alcohol levels, prevent tremors, or treat seizures directly.
A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.
The nurse has reinforced teaching with a client who has gout. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Drink plenty of fluids, including at least 2 L of water daily
- B. Reduce your consumption of alcohol or abstain from drinking
- C. Take aspirin instead of acetaminophen for minor pain or discomfort
- D. Implement a diet and physical activity regimen to maintain a healthy weight
- E. Select protein sources that are low in purine, such as low-fat dairy products
Correct Answer: A,B,D,E
Rationale: Fluids, reduced alcohol, weight management, and low-purine proteins reduce uric acid and gout flares. Aspirin can increase uric acid levels, worsening gout, and should be avoided.
A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?
- A. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive
- B. Place one AED pad on the chest and the other on the back
- C. Place one AED pad on the upper right chest and the other on the lower left side
- D. Place one AED pad on the upper right chest and dispose of the other
Correct Answer: B
Rationale: For a 2-year-old, adult AED pads can be used by placing one on the chest and one on the back to accommodate smaller anatomy. Continuing CPR without AED delays defibrillation, and other options are incorrect pad placements.