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When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
- A. Depression
- B. Excessive sleepiness
- C. A history of cocaine use
- D. A preoccupation with death
Correct Answer: D
Rationale: A key indicator of high risk for suicide in a severely depressed adolescent is a preoccupation with death. This preoccupation may manifest as talking about death frequently, expressing a desire to die, or showing an interest in activities or media related to death. It is important for healthcare providers to take any mention of suicidal thoughts or intentions seriously and to assess for other risk factors. While depression, excessive sleepiness, and a history of cocaine use may also be concerning in an adolescent's mental health assessment, a preoccupation with death is a more direct indicator of suicidal risk. It is crucial for healthcare providers to address suicidal ideation promptly and to ensure the adolescent receives appropriate mental health support and interventions.
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While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
- A. Platelet count, prothrombin time, and partial thromboplastin time
- B. Platelet count, blood glucose levels, and white blood cell (WBC) count
- C. Thrombin time, calcium levels, and potassium levels
- D. Fibrinogen level, WBC, and platelet count
Correct Answer: A
Rationale: When monitoring a client for the development of disseminated intravascular coagulation (DIC), it is important to assess key parameters that can indicate abnormal clotting and bleeding tendencies. The platelet count is essential as DIC can lead to thrombocytopenia (low platelet count). Prothrombin time (PT) and partial thromboplastin time (PTT) are coagulation tests that evaluate the extrinsic and intrinsic pathways of blood clotting, respectively. Prolongation of these times can indicate abnormal coagulation processes seen in DIC. Monitoring these parameters allows healthcare providers to assess and manage DIC promptly to prevent further complications.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.
The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands?
- A. Organize nursing activities to allow for uninterrupted sleep.
- B. Allow the infant to sleep through feedings during the night.
- C. Wait for the infant to cry to show definite signs of hunger.
- D. Discourage parents from rocking the infant
Correct Answer: A
Rationale: Organizing nursing activities to allow for uninterrupted sleep is the most appropriate intervention to decrease cardiac demands in an infant with congestive heart disease (CHD). Providing a peaceful and quiet environment will help in conserving the infant's energy and reducing stress on the heart, ultimately decreasing cardiac demands. Interrupted sleep or inadequate rest can place additional strain on the infant's heart, leading to increased cardiac demands and potential complications. Prioritizing uninterrupted sleep will benefit the infant's overall cardiac function and well-being.
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.
Which nursing consideration is important when caring for a child with impetigo contagiosa?
- A. Apply topical corticosteroids to decrease inflammation.
- B. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
- C. Carefully wash hands and maintain cleanliness when caring for an infected child.
- D. Examine child under a Wood lamp for possible spread of lesions.
Correct Answer: C
Rationale: Carefully washing hands and maintaining cleanliness when caring for an infected child with impetigo contagiosa is important due to its highly contagious nature. Impetigo is a skin infection that is easily spread through direct contact with the lesions or with items contaminated by the infected person such as towels, clothing, or bedding. By washing hands and maintaining cleanliness, caregivers can help prevent the spread of infection to others and minimize the risk of re-infection to the child. This nursing consideration is crucial in managing impetigo and promoting the child's recovery.