Nokea
A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?
- A. Find supplies to put a dressing on the client's wrists
- B. Take the client to a room for supervision by staff
- C. Call the healthcare provider to report the client's behavior
- D. Go find a staff member to stay in the room with the client
Correct Answer: B
Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.
You may also like to solve these questions
A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
- A. Monitor the client's respiratory status
- B. Teach the client how to use the PCA pump
- C. Evaluate the client's pain level
- D. Assess the client's pain level
Correct Answer: A
Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.
The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
- A. Tachycardia, mental status change, and low urine output
- B. Warm skin, hypertension, and constricted pupils
- C. Bradycardia, hypotension, and respiratory acidosis
- D. Mottled skin, tachypnea, and hyperactive bowel sounds
Correct Answer: A
Rationale: The correct answer is A: Tachycardia, mental status change, and low urine output are early signs of shock. Tachycardia is the body's compensatory mechanism to maintain perfusion, mental status changes can indicate decreased cerebral perfusion, and low urine output reflects poor renal perfusion. Choices B, C, and D are incorrect. Warm skin, hypertension, and constricted pupils are not typical findings in the early stages of shock. Bradycardia, hypotension, and respiratory acidosis are more indicative of late-stage shock. Mottled skin, tachypnea, and hyperactive bowel sounds can be seen in various conditions but are not specific early signs of shock.
A nurse is planning care for a client who has a new prescription for metoprolol (Lopressor). Which assessment finding should the nurse report to the healthcare provider before administering the medication?
- A. Heart rate of 50 beats per minute
- B. Blood pressure of 90/60 mm Hg
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 99°F (37.2°C)
Correct Answer: A
Rationale: A heart rate of 50 beats per minute is a concerning finding that should be reported before administering metoprolol. Metoprolol is a beta-blocker that can further lower the heart rate, so a heart rate of 50 bpm indicates potential bradycardia, which is a contraindication for administering this medication. Choices B, C, and D are within normal ranges and do not pose immediate concerns related to metoprolol administration.
A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?
- A. Exhibits adequate tissue perfusion
- B. Remains free of injury
- C. Remains free of infection
- D. Maintains effective breathing pattern
Correct Answer: D
Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.
A male client tells the nurse, 'I am so stressed because I am expected to achieve excellence in everything. My job, my marriage, and my children must be perfect!' Which coping response should the nurse recognize that the client is using?
- A. Repression
- B. Sublimation
- C. Rationalization
- D. Displacement
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice D) involves transferring emotions from one target to another.