Nokea
The practical nurse on the mental health unit is planning care with the registered nurse. Which client should be seen first?
- A. Client with bulimia nervosa who has been in the restroom for the past hour since breakfast
- B. Client with major depressive disorder who has suicidal ideation with a plan and is on one-to-one observation
- C. Client with obsessive-compulsive disorder who refuses to attend group therapy because it interrupts handwashing ritual
- D. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at caregivers
Correct Answer: B
Rationale: Suicidal ideation with a plan (B) poses an immediate safety risk, requiring urgent assessment despite one-to-one observation. Bulimia (A) and schizophrenia (D) behaviors need monitoring but are less acute. OCD refusal (C) is a lower priority, as it does not indicate immediate harm.
You may also like to solve these questions
The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
The nurse is reviewing lifestyle and nutritional strategies to help cables symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.
- A. Choose foods that are low in fat
- B. Do not consume any foods containing dairy
- C. Eat three large meals a day and minimize snacking
- D. Limit or eliminate the use of alcohol and tobacco
- E. Try to avoid caffeine, chocolate, and peppermint
Correct Answer: A,D,E
Rationale: GERD management focuses on reducing esophageal irritation. Low-fat foods (A) reduce gastric acid secretion and reflux risk. Limiting alcohol and tobacco (D) prevents lower esophageal sphincter relaxation and mucosal irritation. Avoiding caffeine, chocolate, and peppermint (E) minimizes sphincter relaxation. Dairy (B) is not universally contraindicated unless lactose intolerance is present. Large meals (C) increase gastric pressure, worsening reflux.
At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:
- A. Reporting the findings to the physician
- B. Evaluating the color of the discharge
- C. Evaluating the client's vital signs
- D. Applying an external fetal monitor
Correct Answer: A
Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.
Which activity is appropriate to assign to a certified nursing assistant?
- A. Evaluate vital signs.
- B. Monitor tube feedings.
- C. Assist with activities of daily living (ADLs).
- D. Discuss discharge instructions.
Correct Answer: C
Rationale: Assisting with ADLs is within a CNA's scope, unlike evaluating vitals, monitoring feedings, or discussing instructions, which require nursing judgment.
The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed
- A. Drawing up the NPH insulin after drawing up the regular insulin
- B. Injecting air into the regular insulin vial after injecting air into the NPH insulin vial
- C. Allowing the tip of the needle to touch the NPH insulin vial while injecting air into the vial
- D. cleaning the tops of both insulin vials with an alcohol swab prior to inserting the needle
Correct Answer: A
Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (A) is incorrect and requires intervention. Injecting air into vials (B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (C) is poor technique but less critical than incorrect insulin order.