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The nurse is caring for a client at risk for suicide. Which client behavior best indicates that the client may be contemplating suicide?
- A. Sharing that she or he is finally happy
- B. Sitting and crying for long periods of time
- C. Preferring to spend long periods of time alone
- D. Reporting a variety of sleep pattern disturbances
Correct Answer: A
Rationale: If a client displays a suicidal ideation and is able to share a plan, it should be taken very seriously and suicide precautions should be implemented. Expressing happiness shows a contentment that is often a sign that a suicide plan has been created. The remaining options are indicative of depression but are not as definitive in regard to suicide.
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A client with a history of atrial fibrillation is admitted with a heart rate of 160 beats per minute. The nurse should prioritize which of the following interventions?
- A. Administer diltiazem as prescribed.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Apply oxygen via nasal cannula.
Correct Answer: A
Rationale: Diltiazem, a calcium channel blocker, is prioritized to control rapid heart rate in atrial fibrillation.
A client with a diagnosis of Tourette's syndrome is receiving haloperidol decanoate. The registered nurse asks the new nurse to describe the action of the medication. The new nurse responds correctly by stating that this medication has which action?
- A. Is a serotonin reuptake blocker
- B. Inhibits the breakdown of released acetylcholine
- C. Blocks the uptake of norepinephrine and serotonin
- D. Blocks the binding of dopamine to the postsynaptic dopamine receptors in the brain
Correct Answer: D
Rationale: Haloperidol decanoate is a typical antipsychotic medication used to manage symptoms of Tourette's syndrome, such as tics, by blocking the binding of dopamine to postsynaptic dopamine receptors in the brain, thereby reducing dopaminergic activity. It does not act as a serotonin reuptake blocker, inhibit acetylcholine breakdown, or block norepinephrine and serotonin uptake.
The nurse should closely monitor the client with an open fracture for which of the following complications?
- A. Avascular necrosis.
- B. Compartment syndrome.
- C. Osteomyelitis.
- D. Fat embolism syndrome.
Correct Answer: C
Rationale: Open fractures have a high risk of osteomyelitis due to exposure to pathogens.
The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
- A. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
- B. Has episodes of vertigo that result in falls.
- C. Has multiple sclerosis with an open, draining lesion on a foot.
- D. Needs stronger lenses for glasses.
Correct Answer: A,B,C
Rationale: Clients requiring prothrombin time monitoring, those with vertigo causing falls, and those with open lesions qualify for home care due to medical needs. Needing glasses does not typically require skilled home care services.
Place these steps of the medication reconciliation process in the correct sequential order from # 1 to # 5. Do NOT include steps that are not part of the medication reconciliation process. 1: Compile a list of newly prescribed medications and other preparations 2: Compile a list of current medications and other preparations 3: Compile a list of only current vitamins, over the counter medications, herbal remedies, nutritional and dietary supplements 4: Compare the two lists and make note of any discrepancies and inconsistencies 5: Employ critical thinking and professional judgments during the comparisons of the two lists 6: Communicate and document the new list of medications to the appropriate healthcare providers
- A. 3,2,1,4,6
- B. 2,1,4,5,6
- C. 1,2,3,5,4
- D. 4,1,3,2,6
Correct Answer: B
Rationale: The medication reconciliation process involves: 1) Compiling current medications, 2) Compiling new medications, 3) Comparing lists for discrepancies, 4) Using critical thinking, 5) Communicating the reconciled list.