Nokea
A spouse brings a client with a history of previous suicide attempts to the emergency department due to erratic behavior and expressions of hopelessness. When the triage nurse asks if the client is having suicidal thoughts, the client shrugs their shoulders. What action should the triage nurse take?
- A. Document that the client is not currently suicidal
- B. Have the client remain in triage and frequently observe for changes
- C. Place the client on one-to-one observation
- D. Return the client to the waiting room with their spouse
Correct Answer: C
Rationale: Given the history of suicide attempts and current hopelessness, a noncommittal response like shrugging suggests a high suicide risk. One-to-one observation ensures safety. Documenting no suicidality is inaccurate, frequent observation is insufficient, and returning to the waiting room is unsafe.
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Social support systems include all of the following except:
- A. call-in help lines.
- B. emotional assistance provided by others.
- C. community support groups.
- D. use of coping skills and verbalization for anger management.
Correct Answer: D
Rationale: Coping skills and verbalization are personal strategies, not social support systems, which involve external resources like help lines, emotional assistance, or groups. Psychosocial Integrity
The nurse is giving instructions to a group of women about breast self-examination. Which statement indicates that the client needs more instruction about the procedure?
- A. I will perform the exam every month after my period.'
- B. I should do the exam both standing and lying down.'
- C. Some ridges are normal in my breast.'
- D. I will do the breast self-exam every month until menopause.'
Correct Answer: D
Rationale: Breast self-exams should continue lifelong, not stop at menopause, as breast cancer risk persists. Other statements reflect correct technique.
A client with chronic kidney disease has an arteriovenous fistula placed in the left wrist for hemodialysis. Which of the following statements indicate that the client understands how to care for the fistula properly? Select all that apply.
- A. I should not worry if I have slight numbness or tingling in my left arm.
- B. I will be sure to avoid sleeping on my left arm.
- C. I will make sure that I always have my blood pressure taken in my left arm.
- D. I will squeeze a small sponge with my left hand several times a day.
- E. I will touch the site and feel for a vibration several times a day.
Correct Answer: B,D,E
Rationale: Avoiding sleeping on the arm prevents pressure on the fistula, squeezing a sponge promotes circulation, and feeling for a thrill ensures patency. Numbness/tingling requires evaluation, and blood pressure should be taken on the opposite arm to avoid fistula damage.
The nurse is observing a staff member perform open suctioning for a client who has a tracheostomy tube. The nurse should intervene if the staff member is observed
- A. flushing the suction catheter with 0.9% sodium chloride after each suction pass
- B. placing the client in the semi-Fowler position prior to suctioning
- C. applying intermittent suction while inserting the suction catheter
Correct Answer: C
Rationale: Applying suction while inserting the catheter can cause tracheal mucosa damage and hypoxia. Flushing the catheter with saline maintains patency, and semi-Fowler position aids breathing and reduces aspiration risk during suctioning.
A young woman is admitted to the hospital complaining of severe fatigue and weakness of several weeks in duration. Her physician suspects a diagnosis of myasthenia gravis. Which additional findings would the nurse expect the client to have?
- A. Ataxia and poor coordination
- B. Diplopia and ptosis of the eyelids
- C. Slurred speech
- D. Headaches and tinnitus
Correct Answer: B
Rationale: Myasthenia gravis causes muscle weakness, commonly manifesting as diplopia and ptosis due to ocular muscle involvement. Ataxia, slurred speech, or headaches are less typical.