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The client is admitted to the inpatient mental health unit. For each potential intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.
- A. Assign the client to a shared room if available
- B. Avoid placing utensils on the client's meal tray
- C. Check on the client at frequent, irregular intervals
- D. Perform frequent room searches for harmful objects
- E. Perform mouth checks after medication administration
- F. Encourage the client to participate in grooming and hygiene
- G. Avoid discussion of suicidal thoughts when talking to the client
Correct Answer:
Rationale: Appropriate interventions for the client with major depressive disorder who is experiencing suicidal ideation include the
following:
• Assigning the client to a shared room near the nurses' station to reduce social isolation and allow easier access to the
client
• Avoiding utensils on the client's meal tray that could be used for self-harm
• Checking on the client at frequent, irregular intervals (if not under 1-to-1 observation) to lessen predictability of staff
surveillance
• Performing frequent room searches for harmful objects to ensure client safety
• Performing mouth checks after medication administration to ensure the client has swallowed medication and is not
saving them for a future overdose attempt
• Encouraging the client to participate in grooming and hygiene because the client may exhibit loss of interest in daily
activities, decreased energy, and lack of motivation
Avoiding discussion of suicidal thoughts is not appropriate. Clients with suicidal ideation are often reluctant to disclose
their thoughts unless asked directly. The nurse should establish a nonjudgmental, therapeutic relationship that allows for open
communication.
It is not appropriate for the nurse to document that the client is not available for a safety check when the client is using the
restroom. The nurse must ensure that there is visual contact with the client during safety checks, even if the client is in the
restroom, to ensure safety.
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Drag words from the choices below to fill in the blanks.The nurse recognizes that the client likely has hyperemesis gravidarum and should monitor for the following maternal complications:---------,------------------, AND -------------
- A. Fluid and electrolyte imbalances
- B. Insufficient gestational weight gain
- C. Intraamniotic infection (chorioamnionitis)
- D. Thyrotoxicosis
- E. Placental abruption
- F. Nutritional deficiencies
Correct Answer: A,B,F
Rationale: Without appropriate treatment, clients with hyperemesis gravidarum are at risk for multiple complications, including:
• Insufficient gestational weight gain, which may be associated with fetal/newborn complications such as preterm birth and a small-for-
gestational-age infant
• Fluid and electrolyte imbalances (eg, hypokalemia) resulting from excessive vomiting and decreased fluid and nutritional intake, whic
could cause life-threatening complications (eg, cardiac dyshythmias) if not corrected
• Nutritional deficiencies (eg, protein, vitamin) resulting from decreased oral intake, which may lead to rare but serious complications
(eg, Wernicke encephalopathy from thiamine [vitamin B1] deficiency)
The nurse has reviewed the information from the Prescriptions. The client received 2 L of lactated Ringer solution IV, 100 mg thiamine IV, and vitamin B, plus doxylamine IV shortly after arrival due to reports of severe nausea and vomiting. Click to highlight below the prescription that the nurse should anticipate completing next when planning care with the registered nurse.
- A. 10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
- B. 1000 mg calcium carbonate q6h
- C. 10 mL multivitamin and 0.6 mg folic acid once daily
- D. 12.5 mg promethazine q6h
Correct Answer: A
Rationale: Clients with hyperemesis gravidarum (HG) may require hospitalization if experiencing hypovolemia and electrolyte abnormalities. On
admission, clients with HG usually receive fluid replacement (eg, lactated Ringer solution) and antiemetics (eg, doxylamine and vitamin Bg).
Thiamine (vitamin B,) is often administered in initial fluids to prevent Wernicke encephalopathy.
For clients with HG experiencing hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) due to vomiting, it is critical to administer potassium
chloride promptly. Hypokalemia can have multiple potentially serious effects that, without intervention, put the client at immediate risk for
death; such effects include cardiac dyshythmia, respiratory muscle weakness causing respiratory failure, and impaired gastrointestinal
motility causing constipation and ileus
Complete the following sentence/sentences by choosing from the list/lists of options.The licensed practical nurse should assist the registered nurse to prepare the client for emergency--------------------------
- A. colonoscopy
- B. CT angiography
- C. Esophagogastroduodenoscopy
Correct Answer: C
Rationale: The nurse should assist in preparing the client for emergency esophagogastroduodenoscopy (EGD). An EGD involves
passing an endoscope down the esophagus to visualize the upper gastrointestinal (Gl) structures (eg, esophagus, stomach,
duodenum), identify the source of the bleed, and perform interventions to stop the bleeding (eg, hemostatic clipping). To
prepare the client for EGD, the nurse should ensure NPO status has been initiated to reduce the risk of aspiration.
Interventions to stabilize the client (eg, IV fluids, blood transfusion) are often initiated before EGD.
The nurse is reinforcing teaching to the client and the parents about management of type 1 diabetes mellitus and prescribed insulin therapy. For each potential instruction, click to specify whether the instruction is appropriate or not appropriate to
include in the teaching
- A. Track carbohydrate intake
- B. Rotate insulin injection sites
- C. Wear a medical alert bracelet
- D. Demonstrate insulin injections on a doll
- E. Store unopened insulin vials at room temperature
Correct Answer:
Rationale: Type 1 diabetes mellitus (DM) is characterized by insulin deficiency and management requires insulin therapy for blood glucose
control. The nurse should provide dietary teaching and instructions for insulin administration. Appropriate instructions to
include in the teaching include:
• Track carbohydrate intake to guide insulin administration and maintain blood glucose levels. Exogenous insulin
administration increases the risk of hypoglycemia. Carbohydrate intake should be relatively consistent each day to avoid
hyperglycemia or hypoglycemia.
• Rotate insulin injection sites to prevent tissue scarring or loss of subcutaneous tissue (ie, lipoatrophy).
• Wear a medical alert bracelet to indicate type 1 DM in the event of hypoglycemia and unconsciousness.
• Demonstrate insulin injections on a doll before performing injections on the child to help prepare the client and family.
Insulin vials that remain unopened should be stored in the refrigerator until opened and can be used up to the expiration date.
Once opened, the vial can be stored at room temperature for approximately 1 month. Injections are less painful when the vial
is stored at room temperature, and lipodystrophy is less likely. Storing the unopened vials at room temperature is not
appropriate to include in the teaching
Drag words from the choices below to fill in the blanks. The nurse gathers supplies for medication administration. The nurse recognizes that the priority prescriptions are -------and ----------
- A. 50% dextrose IV PRN
- B. 0.9% sodium chloride IV bolus
- C. Potassium chloride IV PRN|
- D. Regular insulin continuous IV infusion
- E. 5% dextrose in 0.45% sodium chloride IV infusion
Correct Answer: E,B
Rationale: The priority intervention for management of diabetic ketoacidosis is fluid resuscitation with isotonic IV fluid, typically starting with large-voli
0.9% sodium chloride IV boluses (eg, 1 L/hr) to prevent life-threatening hypovolemic shock. Fluid resuscitation also helps normalize
glucose and electrolyte levels via hemodilution. After initial large-volume boluses are complete, either hypotonic or isotonic IV fluids are
administered at continuous rate. Administration of regular insulin continuous IV infusion is also essential to correct hyperglycemia.