Nokea
Complete the following sentence/sentences by choosing from the list/lists of options. he nurse should prioritize interventions for------- due to the client's -----
- A. Malnutrion
- B. Suicidal Behavior
- C. Substance withdrawal
- D. Recent weight loss
- E. Thoughts of self harm
- F. History of cocaine and marijuana use
Correct Answer: B,E
Rationale: The nurse should prioritize interventions for suicidal behavior due to the client's thoughts of self-harm.
This client has several predisposing factors that increase the risk of suicide, including a psychiatric disorder, previous suicide
attempt, stressful life events (eg, divorce), and substance use. However, the strongest single factor predictive of suicide is the
history of a prior suicide attempt (eg, jumping off a building). The nurse should anticipate implementation of suicide
precautions (eg, 1-to-1 observation).
You may also like to solve these questions
Complete the following sentence by choosing from the lists of options. The nurse suspects the client has ----------- and should implement ----------- precautions.
- A. Influenza
- B. Droplet
- C. Contact
- D. Standard
- E. Hepatitis A
Correct Answer: D,E
Rationale: Hepatitis A is an infection that leads to widespread inflammation of the liver. Transmission occurs through the fecal-oral route and is commo
in areas with overcrowding and poor sanitation. Outbreaks frequently result from contaminated water or food, and the condition is seen
primarily in resource-limited countries. Symptoms develop abruptly, initially including nausea, vomiting, anorexia, fever, and right upper
quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually
followed by jaundice and pruritus. In addition, laboratory results show elevated liver function tests.
Hand hygiene, especially after toileting and before meals, is the most important intervention for reducing the risk of hepatitis A infection.
Therefore, for a client hospitalized with hepatitis A, standard precautions (ie, hand hygiene, disinfection of equipment and surfaces) must be
implemented to prevent transmission. Additional precautions (eg, disposable gown, gloves) should be used as needed (eg, during procedure
For each finding below, click to specify if the finding is consistent with the disease process of acute angle-closure glaucoma, cataracts, or macular degeneration. Each finding may support more than one disease process.
- A. Blind spots
- B. Opaque lens
- C. Blurred vision
- D. Unilateral headache
- E. Conjunctival redness
- F. Nausea and vomiting
- G. Increased intraocular pressure
Correct Answer:
Rationale: Acute angle-closure glaucoma (ACG) is the sudden onset of increased intraocular pressure (IOP) due to impaired aqueous humor drainag
through the angle of the anterior chamber. Acute ACG typically occurs spontaneously but may be triggered by impaired aqueous outflow frol
pupillary dilation (eg, emotional excitement, medications (decongestants, anticholinergics, antihistamines], darkness). As IOP increases,
clients report seeing halos around lights and/or develop blurry vision, unilateral headache, conjunctival redness, and nausea and
vomiting. Increased IOP damages the optic nerve, and the cornea becomes edematous; therefore, light cannot travel effectively from the
cornea to the optic nerve, causing halos to be seen.
Cataracts are a slowly progressive pacification of the lens that results from oxidative damage. Refractive changes in the lens cause clients
to initially develop difficulty reading fine print because of the opaque lens. As the cataract progresses, clients develop painless, blurry visio
and have difficulty with nighttime driving because they see a glare and halos around lights. Halos and glare occur because light cannot
travel through the opacified lens effectively and instead disperses in various angles.
Age-related macular degeneration (AMD) is a progressive, incurable disease of the eye characterized by deterioration of the macula, the
central portion of the retina. This deterioration causes visual disturbances (wavy or blurred vision), blind spots, or loss of the central field
vision; peripheral vision remains intact. AMD has a vascular pathogenesis that is unrelated to increased IOP. Clients with AMD have a norm
cornea, lens, and optic nerve; therefore, halos are not seen.
The nurse has reviewed the information from the Nurses' Notes. For each potential intervention, click to specify if the intervention is anticipated or not anticipated for the care of the client.
- A. Encourage the client to play with others in the playroom
- B. Follow a structured routine and schedule for providing care
- C. Consistently assign the same nursing staff to the client when possible
- D. Assign the client to a shared room with another client who has autism
- E. Use direct eve contact and therapeutic touch when talking to the client
Correct Answer:
Rationale: Clients with autism spectrum disorder (ASD) are often hesitant about changes and have a heightened behavioral response
when placed in an unfamiliar environment (eg, hospital). The nurse should consider the client's unique needs when planning
care. Anticipated interventions for decreasing anxiety and enhancing cooperation when caring for clients with ASD include:
• Following a structured routine and schedule for providing care to reduce distress and promote normalcy
• Consistently assigning the same nursing staff to the client when possible to facilitate trust and communication
because clients with ASD often have difficulties adjusting to changes in their surroundings
• Establishing a method for communication that is brief, concrete, and developmentally appropriate (eg, picture boards) to
decrease frustration due to impaired verbal and nonverbal communication
Clients with ASD are hypersensitive to environmental factors and may become distressed and overstimulated by noise and
activity. Therefore, encouraging the client to play with others in the playroom and assigning the client to a shared room
with another client who has autism are not anticipated
Clients with ASD may be fearful of, or hypersensitive to, touch and direct eye contact. The nurse should use other means of
developing trust (eg, being consistent, conveying acceptance, using positive reinforcement).
I can never get tuberculosis again once I finish treatment
- A. I should take the medications with antacids.
- B. I will notify my health care provider if my urine becomes orange.
- C. I will use additional contraception while taking rifampin
Correct Answer: D
Rationale: Rifampin is often used in the management of both latent and active tuberculosis (TB) but reduces the effectiveness of oral contraceptive
pills. Therefore, the client should be instructed to use additional methods of contraception during treatment and for 1 month following
the completion of treatment (Option 4).
Which of the following findings are consistent with a tension pneumothorax? Select all that apply.
- A. Diminished breath sounds on one side
- B. Dyspnea
- C. Hypotension
- D. Recent thoracic trauma
- E. Tracheal deviation
- F. Unilateral chest wall expansion
Correct Answer: A,B,C,D,E,F
Rationale: A pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion. This
causes the lung to collapse either partially or completely, leading to unilateral, diminished breath sounds; unilateral chest wall
expansion; and dyspnea. A pneumothorax often occurs from blunt thoracic trauma (eg, during a motor vehicle collision). Air can also ent
the pleural space through the chest wall and parietal pleura (open pneumothorax) during or after an invasive procedure on or near the chest
wall (eg, thoracentesis, paracentesis, central line insertion) (Options 1, 2, 4, and 6).