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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.
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History and Physical
Initial vital signs:
Imaging Studies
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD).
She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client.
- A. Monitor cardiac status
- B. Educate on dialysis compliance
- C. Monitor vital signs
- D. Perform head-to-toe assessment
- E. Monitor heart rhythm
- F. Monitor fluid intake and output
- G. Monitor neuromuscular status
Correct Answer: A,B,C,D,E,F,G
Rationale: Monitoring cardiac status, vital signs, heart rhythm, fluid balance, and neuromuscular status, along with educating on dialysis compliance and low-potassium diet, are essential for managing ESRD and hyperkalemia. Transfer to telemetry is not indicated with stable vitals.
A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should be aware of the signs and symptoms of his illness.
- B. The client should plan to participate in group or individual therapy while at college.
- C. Despite the illness, the client should be able to live away from home.
- D. The client's serum lithium levels should be routinely evaluated.
Correct Answer: D
Rationale: Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity, especially critical for a newly diagnosed client transitioning to college.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
- A. The nurse will call the client weekly to monitor the client's blood pressure and symptoms.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain.
- D. The client will record episodes of angina and self-management for one week.
Correct Answer: D
Rationale: Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions. Weekly monitoring, daily walking, and nitroglycerine use are important but do not directly address tracking angina episodes for management.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Compromised family coping.
- B. Ineffective sexual patterns.
- C. Impaired environmental interpretation.
- D. Disturbed sensory perception.
Correct Answer: D
Rationale: Delusional beliefs indicate disturbed sensory perception, the priority problem requiring psychiatric evaluation.