Nokea
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get the provider's discharge order.
- E. Cbe released because you are still suicidal.
- F. You can be released only if you sign a no suicide contract.
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
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The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A.
- A. Which observation indicates appropriate care for an 18-month-old with hepatitis A?
- B. The child is placed in a private room.
- C. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- D. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- E. The staff uses standard precautions.
Correct Answer: A
Rationale: Hepatitis A requires contact precautions for diapered or incontinent patients, including a private room to prevent transmission. Removing toys risks spreading contamination, high-fat snacks are inappropriate, and standard precautions alone are insufficient.
The nurse is teaching testicular self-exam to a group of young men. Which information should be included in the instructions? Select all that apply.
- A. Perform the exam once a week.
- B. Palpate each testicle between the thumb and forefinger.
- C. Palpate the spermatic cord.
- D. Look in the mirror for dimpling.
- E. Testicles should be the same size.
- F. Both testicles should be at the same level.
Correct Answer: B,C
Rationale: Palpating the testicle and spermatic cord detects lumps or abnormalities during testicular self-exam. Monthly (not weekly) exams are recommended, dimpling is for breast exams, and testicles may differ slightly in size and level.
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced lower leg sensation
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.
The client taking allopurinol (Zyloprim) should be taught to:
- A. Drink approximately eight glasses of water per day.
- B. Avoid the intake of fruits.
- C. Allow 6 weeks for the drug to work.
- D. Eat foods containing purine.
Correct Answer: A
Rationale: Allopurinol prevents uric acid buildup, and adequate hydration (eight glasses of water) reduces kidney stone risk. Fruits are not restricted, the drug works sooner, and purine foods should be limited.
The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.5 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.