Nokea
After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse's first priority?
- A. Establish a rapport to foster trust
- B. Place the client in full restraints
- C. Try to communicate with the client in writing
- D. Ensure safety by initiating suicide precautions
Correct Answer: D
Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.
You may also like to solve these questions
A true statement about medications is that:
- A. Over-the-counter medications are unlikely to interact with food or nutrients
- B. Prescription medications always have significant interactions with food
- C. Prescription and nonprescription drugs and herbal remedies interact with food
- D. Herbal products are generally safe since they are natural
Correct Answer: C
Rationale: The correct answer is C. This statement is true because both prescription and over-the-counter medications, as well as herbal remedies, can interact with food. Choice A is incorrect because over-the-counter medications can also interact with food or nutrients. Choice B is incorrect as not all prescription medications have significant interactions with food. Choice D is incorrect because natural herbal products can also have side effects and interactions with other substances.
For a patient with a history of liver disease, which type of diet is most appropriate?
- A. High-protein
- B. High-carbohydrate
- C. Low-protein
- D. Low-fat
Correct Answer: D
Rationale: For a patient with a history of liver disease, a low-fat diet is most appropriate. Liver disease can impair fat metabolism, leading to fat accumulation in the liver cells and worsening the condition. A low-fat diet helps reduce stress on the liver and manage symptoms associated with liver disease. High-protein diets may not be suitable for individuals with liver disease as they can increase the risk of hepatic encephalopathy. High-carbohydrate diets may lead to insulin resistance and fat accumulation in the liver. While protein restriction may be necessary in some cases, a balanced intake of high-quality protein is essential for maintaining muscle mass and overall health, making a low-protein diet not the most appropriate choice for all patients with liver disease.
In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?
- A. Secure a clean container
- B. Discard the container if the outside becomes dirty
- C. Rinse the client's mouth with Listerine before collection
- D. Tell the client that 4 tablespoons of sputum are needed
Correct Answer: A
Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.
Performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: C
Rationale: The correct answer is C: Implementation. In nursing care, implementation involves carrying out and supervising the planned procedures for the patient. This step focuses on putting the care plan into action. Choice A, Evaluation, involves assessing the effectiveness of the care provided, not performing procedures. Choice B, Planning, is about developing a plan of care, not executing it. Choice D, Assessment, is the initial step in the nursing process where data is collected and analyzed to determine the patient's needs, not the step involving performing and supervising procedures.
Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of training soldiers for survival on the battlefield?
- A. Accountability
- B. Personal/professional development
- C. Individual training
- D. Military appearance/physical condition
Correct Answer: C
Rationale: The correct answer is C: Individual training. Individual training involves preparing soldiers for specific tasks like survival on the battlefield. Accountability (choice A) refers to being answerable for one's actions, not directly related to training soldiers. Personal/professional development (choice B) focuses on growth and advancement of individuals, not specific training for battlefield survival. Military appearance/physical condition (choice D) pertains to the physical attributes and presentation of soldiers, not directly related to training them for survival.