Nokea
The nurse in the emergency department is caring for assigned clients. The nurse should recognize that which of the following clients meets the criteria for involuntary admission to the mental health unit? Select all that apply.
- A. the client with major depressive disorder who has refused food and fluids for the past 4 days
- B. the client with schizophrenia who takes prescribed antipsychotic medication
- C. the client who repeatedly mumbles, 'I must kill them before they get me.'
- D. the client who states, 'I sleep on the floor rather than in a bed.'
- E. the client with cannabis found in personal belongings
Correct Answer: A,C
Rationale: Refusal of food and fluids for 4 days indicates imminent risk of harm to self due to dehydration and malnutrition, meeting involuntary admission criteria. 3: Threats of violence suggest potential harm to others, justifying involuntary admission. 2 does not indicate immediate risk, as the client is medication-compliant. 4 reflects unusual behavior but not immediate danger. 5 does not inherently indicate a psychiatric emergency requiring involuntary admission.
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What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)?
- A. Symptom relief occurs in a few days
- B. Alcohol use is to be avoided
- C. Medication must be stored in the refrigerator
- D. Episodes of diarrhea can be expected
Correct Answer: B
Rationale: Alcohol potentiates the action of tricyclic antidepressants.
The nurse is planning care for a 6-month-old client admitted with bacterial meningitis. Which nursing action is the priority?
- A. Apply padding to the crib side rails
- B. Document head circumference daily
- C. Implement a low-stimuli environment
- D. Initiate antibiotic therapy as prescribed
Correct Answer: D
Rationale: Prompt antibiotic therapy is critical to treat bacterial meningitis and prevent complications or death, making it the priority. A, B, and C are important but secondary; padding prevents injury, daily head circumference monitors for hydrocephalus, and a low-stimuli environment reduces seizure risk, but none address the infection directly.
A nurse is assisting with preventive health screenings at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.
- A. For the past few years, I get a productive cough in the winter that goes away in the spring
- B. I occasionally have heartburn an hour after I eat fried foods and sausage.
- C. Last month when I was doing my breast self-examination, I noticed a marble-sized lump.
- D. My mole is itchy, and the edges have become uneven with a blackish to bluish color.
- E. Recently I have noticed that my bowel movements appear black.
Correct Answer: C,D,E
Rationale: A breast lump, an asymmetrical/irregular mole, and black stools are potential cancer signs (breast cancer, melanoma, gastrointestinal cancer). Seasonal cough and occasional heartburn are less concerning.
All of the following women are seen in the physician's office. Which is at greatest risk for preterm labor?
- A. A primigravida who has gained 30 lb during her pregnancy
- B. A 35-year-old carrying a small baby
- C. A 21-year-old pregnant with twins
- D. A 40-year-old who has four other children
Correct Answer: C
Rationale: Multiple gestation, such as twins, significantly increases preterm labor risk due to uterine overdistension, making the 21-year-old the highest risk.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct Answer: C
Rationale: Manage pain. The immediate goal of therapy is to alleviate the client's pain, which can be quite severe with kidney stones.