Nokea
The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.
- A. I am currently unemployed and looking for a job
- B. I have been married for five years with three children
- C. I have multiple firearms at home stored in a safe
- D. I have been about a year since I last overdosed
- E. I attend weekly religious activities with my family
- F. Sometimes I experience feelings of hopelessness
Correct Answer: A,C,D,F
Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.
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The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
- A. Ask family members to dress the client
- B. Encourage the client to dress more quickly
- C. Allow the client the time needed to dress
- D. Demonstrate methods on how to dress more quickly
Correct Answer: C
Rationale: Allow the client the time needed to dress. Clients with Parkinson's disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all.
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
- A. A 13 month-old unable to walk
- B. A 20 month-old only using 2 and 3 word sentences
- C. A 24 month-old who cries during examination
- D. A 30 month-old only drinking from a sippy cup
Correct Answer: D
Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.
The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:
- A. Infection with the tubercle bacillus
- B. Exposure to the tubercle bacillus
- C. Questionable exposure to the tubercle bacillus
- D. No exposure to the tubercle bacillus
Correct Answer: B
Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.