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In developing a plan of care for a client admitted to a mental health unit after attempting suicide by taking a handful of medications, which goal has the highest priority?
- A. Signs a no-self-harm contract
- B. Sleep for at least 6 hours nightly
- C. Attends group therapy every day
- D. Verbalizes a positive self-image
Correct Answer: A
Rationale: The correct answer is A: Signs a no-self-harm contract. Ensuring the client's immediate safety by having them commit to not engaging in self-harm is the highest priority after a suicide attempt. This measure aims to prevent further harm to the client. While sleep, group therapy, and self-image are important aspects of care, they are secondary to ensuring the client's safety in the immediate aftermath of a suicide attempt. Prioritizing the establishment of a no-self-harm contract creates a foundation for addressing other therapeutic goals in the client's care plan.
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Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?
- A. Administer regular insulin per sliding scale
- B. Cancel the client's dinner tray
- C. Give the client 4 ounces (120 mL) of orange juice
- D. Administer the next scheduled dose of metformin
Correct Answer: A
Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.
A male client, admitted to the mental health unit for a somatoform disorder, becomes angry because he cannot have his pain medication. He demands that the nurse call the healthcare provider and threatens to leave the hospital. What action should the nurse take?
- A. Place the client in seclusion per unit guidelines
- B. Administer a PRN prescription for lorazepam (Ativan)
- C. Call security to help ensure staff and client safety
- D. Ask what other methods he uses to deal with pain
Correct Answer: C
Rationale: In this scenario, the nurse should prioritize ensuring safety. When a client becomes aggressive and threatens to leave, calling security is crucial to help maintain a safe environment for both staff and the client. Placing the client in seclusion (choice A) is not the appropriate initial action as it may escalate the situation further. Administering lorazepam (choice B) should not be the first response to behavioral issues. Asking about other pain management methods (choice D) is not the immediate priority when safety is at risk.
After assessing an older adult with a suspected cerebrovascular accident (CVA), the nurse documents the client's right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, and the neurological assessment remains unchanged, which action should the nurse implement first?
- A. Administer an oral analgesic with antiemetic
- B. Collect blood for coagulation times
- C. Send the client for a computed tomography scan of the brain
- D. Obtain a history of medication use, recent surgery, or injury
Correct Answer: C
Rationale: In this scenario, the priority action for the nurse is to send the client for a computed tomography (CT) scan of the brain. A CT scan is crucial in assessing acute changes or bleeding that could influence treatment decisions in a suspected cerebrovascular accident (CVA). While addressing symptoms like headache and nausea is important, ruling out acute changes in the brain with a CT scan takes precedence in this situation. Collecting blood for coagulation times may be necessary but is not the initial priority. Obtaining a history of medication use, recent surgery, or injury is also important but not the first action to take when a CVA is suspected.
A client presents to the healthcare provider with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been using over-the-counter ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test should the nurse report to the healthcare provider?
- A. Sedimentation rate
- B. White blood cell count
- C. Anti-CCP antibodies
- D. Activated Clotting Time
Correct Answer: A
Rationale: The correct answer is A: Sedimentation rate. Sedimentation rate, Anti-CCP antibodies, and C-reactive protein are commonly used laboratory tests to indicate inflammation and help diagnose rheumatoid arthritis. An elevated sedimentation rate is a nonspecific indicator of inflammation in the body, which is often seen in RA. White blood cell count is not specific for RA and is not typically significant in the diagnosis. Anti-CCP antibodies are specific to RA and are useful in confirming the diagnosis. Activated Clotting Time is not relevant to the diagnosis of rheumatoid arthritis as it is not specific to this condition.
A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client's plan of care?
- A. Encourage speaking slowly and articulating words
- B. Sit upright and flex chin forward while swallowing
- C. Position a communication board at the bedside
- D. Provide feeding utensils with large grip handles
Correct Answer: B
Rationale: The correct intervention for a client with ALS experiencing difficulty swallowing and articulating words is to sit upright and flex the chin forward while swallowing. This position helps manage dysphagia associated with ALS by facilitating the swallowing process. Encouraging speaking slowly and articulating words (Choice A) may be helpful for speech clarity but does not address the swallowing issue. Positioning a communication board (Choice C) would not directly address the swallowing difficulty. Providing feeding utensils with large grip handles (Choice D) is not the priority intervention for managing dysphagia in ALS.