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The client reports manifestations of depression.
A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. The client is married and has children.
- B. The client has a strong religious affiliation.
- C. The client recently received a pay raise at work.
- D. The client has a history of chronic back pain.
Correct Answer: D
Rationale: Chronic pain increases suicide risk due to persistent distress.
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The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.
A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?
- A. Turn on overhead lights briefly when checking IV lines.
- B. Wear shoes with rubber soles.
- C. Open curtains between clients in semiprivate rooms.
- D. Conduct change-of-shift report near the clients' rooms.
Correct Answer: B
Rationale: Rubber-soled shoes reduce noise, improving sleep environment.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.
A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
- A. Educate the infant's guardians about exchange transfusion.
- B. Administer granulocyte colony-stimulating factor.
- C. Initiate droplet precautions.
- D. Monitor the infant's lymphocyte count.
Correct Answer: D
Rationale: Monitoring lymphocyte count tracks HIV progression in infants.
A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Persistent uterine contractions
- B. Increased fetal movement
- C. Rigid abdomen
- D. Bright red vaginal bleeding
Correct Answer: D
Rationale: Bright red vaginal bleeding is characteristic of placenta previa.