Nokea
While planning nursing process for a patient who is at risk for suicide, which of the following is the priority area for providing care :
- A. Sleep
- B. Nutrition
- C. Self-esteem
- D. Safety
Correct Answer: D
Rationale: Suicide risk demands a prioritized nursing approach under the nursing process. Sleep (choice A) and nutrition (choice B) are basic needs, but disruptions are secondary to immediate risk. Self-esteem (choice C) influences mental health, yet addressing it is a longer-term goal. Safety (choice D) is the priority, as suicidal ideation poses an acute threat to life, requiring immediate interventions like removing hazards, constant observation, and risk assessment (e.g., SAD PERSONS scale). D is correct because ensuring safety prevents harm, the first step in stabilizing the patient. Nurses must implement safety protocols, collaborate with psychiatry, and then address sleep, nutrition, and esteem, building a comprehensive care plan.
You may also like to solve these questions
The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?
- A. Suction the client every hour
- B. Maintain the head of the bed at 30 degrees
- C. Encourage the client to cough frequently
- D. Administer a bolus of intravenous fluids
Correct Answer: B
Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Stages of Change Model, which stage of change is the client in related to diet?
- A. Precontemplation
- B. Contemplation
- C. Preparation
- D. Maintenance
Correct Answer: A
Rationale: The Stages of Change Model tracks behavior shift, and this client's denial of diet's role in heart disease places them in precontemplation. Here, individuals show no intent to change within six months, often resisting evidence like diet's link to atherosclerosis clinging to beliefs that meds alone suffice. Contemplation involves considering change, preparation plans it, and maintenance sustains it none apply, as the client isn't pondering dietary shifts. This stage reflects unawareness or defiance, common post-surgery when focusing on recovery, not prevention. Nursing must gently challenge this, using education like explaining sodium's impact on heart strain to nudge awareness, critical for moving them toward contemplation and eventual heart-healthy habits, preventing further cardiac issues.
When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.
Small for gestational age and large for gestational age infants have polycythemia because of:
- A. Hypocalcemia
- B. Hypoglycemia
- C. Hypoxia
- D. Hypothermia
Correct Answer: C
Rationale: Polycythemia (high red blood cell count) in SGA and LGA infants relates to intrauterine conditions. Hypocalcemia (choice A) affects calcium, not blood cells. Hypoglycemia (choice B) is metabolic, common in both, but unrelated to polycythemia. Hypoxia (choice C) triggers erythropoietin release, increasing RBCs; SGA infants face placental insufficiency, LGA infants (e.g., diabetic mothers) experience transient hypoxia. Hypothermia (choice D) doesn't cause polycythemia. C is correct, as hypoxia drives this adaptation. Nurses monitor hematocrit, manage viscosity risks (e.g., dehydration), and support oxygenation, preventing complications.