Nokea
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.
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Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease.
- B. Familial history of mental illness.
- C. Current weight.
- D. Medication history.
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
- A. The nurse will call the client weekly to monitor the client's blood pressure and symptoms.
- B. The nurse will encourage the client to walk thirty minutes every day.
- C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain.
- D. The client will record episodes of angina and self-management for one week.
Correct Answer: D
Rationale: Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions. Weekly monitoring, daily walking, and nitroglycerine use are important but do not directly address tracking angina episodes for management.
A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
- A. Provide a supportive, structured environment for meals.
- B. Assess weight, vital signs, potassium, and other electrolytes.
- C. Discuss alternative strategies for binging and purging.
- D. Monitor the client after meals for possible vomiting.
Correct Answer: B
Rationale: Assessing weight, vital signs, and electrolytes is critical to identify life-threatening complications of bulimia, taking precedence over other interventions.
History and Physical
Laboratory Results
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis 2
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room, and another set of vital signs is performed. Physician notified and orders received
Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
- A. Basic metabolic panel
- B. Echocardiogram
- C. CT scan of abdomen
- D. Blood cultures times 2 sets
- E. Chest X-ray
- F. Place on a continuous cardiac monitor
- G. CBC
Correct Answer: E,F
Rationale: Chest X-ray and continuous cardiac monitoring are priorities to assess chest discomfort and potential arrhythmias in a client with CAD and hyperkalemia risk. Other orders are important but less urgent.