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A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. Which knowledge should the nurse use to provide support to the client?
- A. The client is HIV positive, but the client's CD4 cell count is high.
- B. The client is HIV positive, but the disease has been detected early.
- C. There are occasional false-positive readings with this test; results can be verified by repeating it one more time.
- D. False-positive results can occur, and more testing is needed before diagnosing the client as being HIV positive.
Correct Answer: D
Rationale: If the client tests positive for HIV with the ELISA test, the test is repeated because of the potential for a false-positive result (e.g., from a recent influenza or hepatitis B vaccine) or a false-negative result if drawn too early after infection. If the test is positive a second time, the Western blot (a more specific test) is done to confirm the finding. The client is not diagnosed as HIV positive unless the Western blot is positive. Some laboratories also run the Western blot a second time with a new specimen before making a final determination.
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An adolescent is preparing to return home after psychiatric hospitalization for a suicide attempt. Which actions would be most effective to support family processes when the client returns home?
- A. Make a video of the ride home in the car.
- B. Identify the family's strengths and weaknesses.
- C. Ask that the mother's boyfriend move out of the home.
- D. Provide and offer the family appropriate options and resources.
- E. Encourage communication and the sharing of feelings among the family members.
Correct Answer: B,D,E
Rationale: After the crisis time of a family member's suicide attempt, safety for the recovering individual is a priority. Families can provide support and encouragement in a caring home environment. Options 2, 4, and 5 offer helpful ways to enhance the family processes. Options 1 and 3 are clearly the least effective options because there is no information in the question that indicates that these actions are relative to the suicide attempt.
The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?
- A. Instruct the client to add regular exercise to their daily routine.
- B. Determine if the client has been keeping a sleep diary.
- C. Encourage the client to continue the routine until sleep is achieved.
- D. Ask the client to describe the routine they are currently following.
Correct Answer: D
Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.
Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
- A. Ask the client to remain quiet so the procedure can be performed safely.
- B. Concentrate on completing the insertion as efficiently as possible.
- C. Calmly reassure the client that the discomfort will be temporary.
- D. Tell the client a joke as a means of distraction from the procedure.
Correct Answer: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?
- A. Implement suicide precautions.
- B. Frequently offer high-calorie snacks and fluids.
- C. Assist the patient to identify three personal strengths.
- D. Observe patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.