Nokea
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.
- C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.
- D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.
Correct Answer: C
Rationale: Close monitoring and intervention are critical to prevent self-harm in a client showing signs of distress, prioritizing safety.
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A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Teach the client to develop a plan for daily structured activities.
- B. Encourage the client to exercise.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Provide education on methods to enhance sleep.
Correct Answer: A
Rationale: Structured daily activities provide purpose and combat psychomotor retardation and lack of motivation, key to restoring function.
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.
The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap is too harsh for the radiation site, indicating a need for further teaching. Prescribed lotions, protective clothing, and patting to dry are appropriate.
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.
An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?
- A. Vomiting, seizures, and loss of consciousness.
- B. Agitation, sweating, and abdominal cramps.
- C. Depression, fatigue, and dizziness.
- D. Hypotension, shallow respirations, and dilated pupils.
Correct Answer: B
Rationale: Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal, consistent with opioid use suggested by needle marks.