Nokea
A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse 'I've made some decisions about my life.' What should be the nurse's initial response?
- A. You've made some decisions.
- B. Are you thinking about killing yourself?
- C. I'm so glad to hear that you've made some decisions.
- D. You need to discuss your decisions with your therapist.
Correct Answer: B
Rationale: Are you thinking about killing yourself? This validates suicidal ideation to assess the seriousness of the risk.
You may also like to solve these questions
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.
A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information
An adult has been diagnosed with gout. Which comment by the client indicates to the nurse that the client understands management of the condition?
- A. It has been hard to give up chicken and liver.'
- B. I have shrimp two or three times a week.'
- C. My favorite snack is nuts.'
- D. I have oatmeal every day for breakfast.'
Correct Answer: D
Rationale: Oatmeal is low-purine, suitable for gout management, unlike chicken, liver, or shrimp, which are high-purine and increase uric acid. Nuts are moderate and less ideal.
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.
A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?
- A. Report this immediately to the nurse manager
- B. Confront the nurse about the suspected drug use
- C. Sign the narcotic sheet and document the event in an incident report
- D. Counsel the colleague about the risky behaviors
Correct Answer: A
Rationale: The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an incident that a co-worker can resolve without referral to a manager.