A client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. Which intervention during the
... [Show More] first 6 hours following admission should the RN identify as the priority?
A. Give lorazepam (Ativan) PRN for signs of withdrawal.
B. Administer disulfiram (Antabuse) immediately.
C. Place in a side lying position with head of bed elevated.
D. Provide thiamine and folate supplements as prescribed.
When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take?
A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
B. Withhold the medication until the dosage can be confirmed.
C. Inform him that he may refuse the medication and document whether or not he takes it.
D. Explain to the client that the dosage has been changed.
The nurse orients a female client with depression to the new room on the mental health unit. The client states “It seems strange that I don’t have a T.V in my room.” Which statement would be best for the RN to provide?
A. “You can watch T.V as much as you want outside of your room.”
B. “Sometimes clients feel like the T.V is sending them messages.” C. “It’s important to be out of you room and talking to others.”
D. “Watching T.V is a passive activity and we want you to be active.”
The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP?
A. Potassium level of 2.9 mEq/dl.
B. Blood pressure of 110/70 mmHg.
C. WBC of 10,000mm^3.
D. Body mass index of 21.
The Rn is planning client teaching for a 35-year-old client with alcoholic cirrhosis. Which self-care measure should the RN emphasize for the client’s recovery?
A. Support group meetings.
B. Vitamin B and multivitamin supplements.
C. Diet with adequate calories and protein.
D. Alcohol abstinence.
A teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the RN to include in the clients plan of care?
A. Implement behavioral modification therapy.
B. Initiate caloric and nutritional therapy.
C. Evaluate the client for low self-esteem.
D. Record daily weights and graft trend.
While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note- taking during an interview?
A. The client’s comfort level is increased when the RN breaks eye contact to take notes.
B. The interview process is enhanced with note taking and allows the client to speak at a normal pace.
C. Taking notes during an interview is a legal obligation of examining RN.
D. The RN’s ability to directly observe the client’s non-verbal communication is limited with note taking.
A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
a. Client will not demonstrate cross addiction.
b. Co-dependent behaviors will be decreased. c. CNS stimulation will be reduced.
d. Client's level of consciousness will increase.
A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take?
a. Notify the physician immediately and force fluids. b. Prior to giving the next dose, notify the physician of the symptoms.
c. Record the symptoms and continue medication as prescribed.
d. Hold the medication and refuse to administer additional amounts of the drug.
While caring for an older client, the RN observes multiple bruises in Over the client’s legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take?
A. Report family conversations and anger towards the client when visiting.
B. Ask the client specific questions about someone causing the bruising.
C. Question the family members and caregiver how the bruising occurred. D. Measure and document size, shape and color of the bruised areas.
The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?
A. Benzodiazepine
B. Alcohol C. Methamphetamine
D. Marijuana
After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school’s work study program. What action should the RN take?
A. Suggest that the student work in the athletic department.
B. Determine the parent’s opinion of the work assignments.
C. Refer the student to a psychiatrist for further discussion. D. Recommend assignment to the receptionist’s office.
A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take?
A. Encourage the client to stay in the hospital so the client does not have to be homeless. B. Provide the client with medication if the client presents an imminent risk to self and others.
C. Administer a long acting antipsychotic medication so that the client can be discharged to a shelter.
D. Describe to the client treatment options provided at the community mental health clinics.
A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client?
A. When was the last time you drank alcoholic beverage? B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure? [Show Less]