Nokea
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
- A. I just feel like my life is filled with emptiness.'
- B. I have three firearms locked in a safe at home.'
- C. My daughter is the only reason I keep trying.'
- D. My panic attacks happen once every month.'
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.
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A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
- A. Postpone the client interview until the next day.
- B. Document the client's paranoid behavior.
- C. Attempt to ask the client simple questions.
- D. Ask another nurse to talk with the client.
Correct Answer: C
Rationale: Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish rapport. Postponing delays care, documenting should follow engagement, and involving another nurse is a later option.
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
Laboratory Test
Result
Glucose
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dim (4.1 to 5.9 mmol/L)
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue, Generalized weakness, Muscle cramps, Tingling sensation in her arms and legs, Lightheadedness. She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
- A. Muscle cramps
- B. Tingling sensation in her arms and legs
- C. Lightheadedness
- D. Fatigue
- E. Generalized weakness
Correct Answer: A,B,C
Rationale: Muscle cramps, tingling sensation, and lightheadedness are signs of electrolyte imbalance, likely due to missed dialysis, which can lead to serious complications like cardiac arrhythmias. The nurse should monitor vital signs, neurological status, and notify the physician.
A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
- A. Provide a supportive, structured environment for meals.
- B. Assess weight, vital signs, potassium, and other electrolytes.
- C. Discuss alternative strategies for binging and purging.
- D. Monitor the client after meals for possible vomiting.
Correct Answer: B
Rationale: Assessing weight, vital signs, and electrolytes is critical to identify life-threatening complications of bulimia, taking precedence over other interventions.
History and Physical
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. Nurses' Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.
- A. The client discusses moving to Hawaii instead of returning to rebuild her house. (Fantasy)
- B. The client seems unemotional when talking about needing to rebuild her house. (Isolation)
- C. The client states that she sometimes forgets why she is in the hospital. (Suppression)
- D. The client is frightened that the hospital will burn down. (Denial)
Correct Answer: A,B,C,D
Rationale: Fantasy (Hawaii move) escapes reality, isolation (unemotional) separates emotions, suppression (forgetting hospitalization) avoids distress, and denial (hospital fire fear) projects trauma.