Nokea
Susan,the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?
- A. Lethality of the method and availability of means
- B. Client's educational and economic background
- C. Client's insight into the reasons for the decision
- D. Quality of the client's social support
Correct Answer: A
Rationale: The correct answer is A. Assessing the lethality of the method and availability of means is the priority because it directly addresses the client's immediate safety. Understanding how easily the client can access the means to commit suicide is crucial in preventing harm. Choices B, C, and D are important aspects of a comprehensive assessment but do not directly address the immediate risk of suicide. Choice B focuses on background information, which may be relevant for understanding the client but is not the priority in this urgent situation. Choice C pertains to the client's insight, which is important for therapeutic interventions but does not address the imminent risk. Choice D considers social support, which is valuable in long-term prevention but not the immediate concern.
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Give Dobutamine 5.5 mcg/kg/min. The drug is available as 750 mg in 500 ml of fluid. The client weighs 220 pounds. Calculate mcg/min, mcg/hr, and ml/hr. (Include the unit of measure for each answer).
Correct Answer: 22
Rationale: To calculate mcg/min: 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. To convert mcg/hr: 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. To find ml/hr: 750 mg / 500 ml = 1.5 mg/ml. 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. 66,000 mcg/hr / 1,000 = 66 mg/hr. 66 mg/hr / 1.5 mg/ml = 44 ml/hr. Therefore, the correct answer is 22 mcg/min, 66,000 mcg/hr, and 44 ml/hr. Other choices are
A nurse is interviewing a school-age child who has intermittent explosive disorder (IED). Which of the following behaviors should the nurse expect the client to exhibit?
- A. Lack of remorse for behavior
- B. Mild outbursts with provocation
- C. Blaming others for their behavior
- D. Difficulty coping with stressors
Correct Answer: A
Rationale: The correct answer is A: Lack of remorse for behavior. In intermittent explosive disorder (IED), individuals exhibit sudden and intense episodes of aggression or violence. They may act impulsively without considering consequences or feeling remorse afterward. This lack of remorse is a key characteristic of IED, distinguishing it from other behavioral disorders like conduct disorder where remorse might be present. Choices B, C, and D are incorrect because mild outbursts with provocation, blaming others for behavior, and difficulty coping with stressors are not specific to IED but can be seen in various other behavioral disorders or stress-related conditions.
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Tremors
- B. Hyperglycemia
- C. Insomnia
- D. Visual hallucinations
- E. Severe hypotension
Correct Answer: A,C,D
Rationale: Tremors insomnia and hallucinations are typical alcohol withdrawal symptoms.
Which of the following is a risk factor for shaken baby syndrome?
- A. Low socioeconomic status
- B. Inadequate parental education
- C. Having multiple siblings
- D. Physical disability of the caregiver
Correct Answer: A
Rationale: The correct answer is A: Low socioeconomic status. Low socioeconomic status can lead to increased stress levels and lack of access to resources, increasing the likelihood of caregiver frustration and potential for shaken baby syndrome. Inadequate parental education (B) may contribute, but is not as directly linked. Having multiple siblings (C) and physical disability of the caregiver (D) are not direct risk factors for shaken baby syndrome.
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
- A. Warn the client that further disruptions will result in seclusion.
- B. Ask the client to recommend consequences for her disruptive behavior.
- C. Set limits on the client's behavior and be consistent in approach.
- D. Ignore the client's behavior,realizing it is consistent with her illness.
Correct Answer: C
Rationale: The correct answer is C: Set limits on the client's behavior and be consistent in approach. This is the best course of action because it maintains a therapeutic environment while ensuring the safety and well-being of all clients. By setting limits, the nurse establishes boundaries for acceptable behavior during the manic episode, helping to prevent harm and maintain order on the unit. Consistency in approach is crucial to provide the client with structure and predictability, which can help manage the manic symptoms and reduce potential disruptions.
Choice A is not the best option as it may escalate the situation and does not address the underlying issue. Choice B is not appropriate as it puts the responsibility on the client to determine consequences, which may not be effective in managing the behavior. Choice D is incorrect as ignoring the behavior can compromise the safety of other clients and is not a therapeutic approach to managing manic episodes.