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A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate?
- A. Noting that symptoms of physical illness are not relevant to the current diagnosis
- B. Asking the patient if she has ever thought about taking her own life
- C. Conducting interviews in a brief and direct manner
- D. Arranging for the patient to spend time alone to consider her feelings
Correct Answer: B
Rationale: Screening for suicidal ideation is critical in depression to assess risk. Physical symptoms are relevant, interviews should be empathetic, and leaving the patient alone risks suicide.
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The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
- A. Encouraging the patient to gain a sense of control over his or her life
- B. Collecting sufficient evidence to secure a criminal conviction
- C. Helping the patient understand that this will not happen again
- D. Encouraging the patient to verbalize what happened during the assault
Correct Answer: A
Rationale: Nursing interventions post-sexual assault focus on empowering the patient to regain control, prioritizing emotional recovery over legal outcomes, future safety guarantees, or forced verbalization.
A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action?
- A. Refer the family to psychiatry in order to provide them with support.
- B. Explore the causes of the patient's suicide attempt with the family.
- C. Encourage the family to participate in the bedside care of the patient.
- D. Ensure that the family receives appropriate crisis intervention services.
Correct Answer: D
Rationale: Crisis intervention services support the family after a suicide attempt. Exploring causes is insensitive, bedside care is impractical, and psychiatry isn't the primary support source.
The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient?
- A. How would you describe your mood over the past few days?
- B. Have you ever thought about taking your own life?
- C. How do you think that your life is most likely to end?
- D. How would you rate the severity of your depression right now on a 10-point scale?
Correct Answer: B
Rationale: Directly asking about suicidal thoughts is essential for risk assessment in depression. Mood, life expectancy, or severity ratings are less specific for suicide screening.
A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
- A. Check the patient's blood glucose level.
- B. Assess for a documented history of major depression.
- C. Determine whether the patient has ingested a corrosive substance.
- D. Arrange for assessment of serum potassium levels.
Correct Answer: A
Rationale: Hypoglycemia can mimic alcohol intoxication symptoms like confusion and slurred speech, so checking blood glucose is critical. Depression, corrosive ingestion, or potassium levels are less likely mimics.
The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?
- A. Hypertension with a wide pulse pressure
- B. Anhidrosis
- C. Copious diuresis
- D. Cheyne-Stokes respirations
Correct Answer: B
Rationale: Heat stroke is characterized by anhidrosis (lack of sweating), hot dry skin, and hyperthermia. It causes hypotension, not hypertension, and is not linked to diuresis or Cheyne-Stokes breathing.