Nokea
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest
- A. during the night shift when staffing is limited
- B. when the client's mood improves with an increase in energy level
- C. at the time of the client's greatest despair
- D. after a visit from the client's estranged partner
Correct Answer: B
Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.
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The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
- A. You need to regain your strength before attempting such exertion.'
- B. When you can climb 2 flights of stairs without problems, it is generally safe.'
- C. Have a glass of wine to relax you, then you can try to have sex.'
- D. If you can maintain an active walking program, you will have less risk.'
Correct Answer: B
Rationale: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
As adult is admitted with bleeding esophageal varices, and a triple-lumen nasogastric tube is inserted and the balloons inflated. What should the nurse keep at the bedside because the client has this tube?
- A. Adhesive tape
- B. A syringe with water
- C. Scissors
- D. A clamp
Correct Answer: C
Rationale: Scissors are kept at the bedside to cut and release the tube if the balloons cause airway obstruction or excessive pressure, a critical safety measure for triple-lumen tubes like the Sengstaken-Blakemore.
The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting recreational substances. The parents ask the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?
- A. I know it must be terrible to see your child like this, but your child will be fine within a few days.
- B. It is important to understand that most people have permanent adverse effects after an episode like this.
- C. We cannot predict whether your child will develop schizophrenia; close observation is required to determine the cause of psychosis.
- D. Your child would be fine right now if they had not taken these drugs. We will need to do some additional testing
Correct Answer: C
Rationale: Schizophrenia risk cannot be predicted from a single episode; observation is needed. Reassurance , permanent effects , and blame are inaccurate.
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to the client on what possible adverse effect?
- A. Hypernatremia
- B. Sexual dysfunction
- C. Urinary retention
- D. Weight loss
Correct Answer: B
Rationale: Sertraline commonly causes sexual dysfunction, a significant side effect. Hypernatremia , urinary retention , and weight loss are less common.
The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?
- A. Attempt to answer the client's questions
- B. Notify the physician of the client's concerns prior to medicating the client
- C. Reassure the client that the physician is well respected and very competent
- D. Suggest that the client ask the physician her questions when in the operating room
Correct Answer: B
Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.