Nokea
A physical assessment is performed on a suicidal client upon admission to the inpatient unit. The nurse understands its importance because it provides information regarding which priority assessment data?
- A. The presence of abnormalities
- B. Evidence of physical self-harm
- C. Both subjective and objective baseline data
- D. Existing medical problems and complaints
Correct Answer: B
Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the client's formulation of a plan for the suicide attempt. Although all of the choices are correct, preventing self-harm is the priority in the context of the suicidal client. Clients with a history of self-harm are greater suicide risks.
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The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
- A. Administer the dose as ordered.
- B. Hold the dose and notify the physician.
- C. Administer half the prescribed dose.
- D. Administer vitamin K as an antidote.
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
A client with a history of chronic lymphocytic leukemia is admitted with fatigue. The nurse should monitor the client for which of the following?
- A. Anemia.
- B. Hyperkalemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Chronic lymphocytic leukemia can cause anemia due to bone marrow suppression, leading to fatigue.
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.
When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?
- A. Questioning the client about how much alcohol she drinks.
- B. Confronting the client with the fact that she was intoxicated 2 days ago.
- C. Pointing out how alcohol has gotten her into trouble.
- D. Listening to what the client states and then asking her how she plans to stay sober.
Correct Answer: D
Rationale: This approach uses therapeutic communication, acknowledging the client's perspective and encouraging problem-solving, which is effective for addressing denial in alcohol dependency.
A client with a history of depression is prescribed paroxetine (Paxil). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Suicidal thoughts.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Suicidal thoughts are a serious side effect of paroxetine, requiring immediate reporting to ensure client safety.