A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Assess the client's ability to communicate with the other staff members.

Arrange a meeting with the family to discuss the client's situation.

Administer the client's antidepressant medication as prescribed.

Establish a structured routine for the client to follow.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

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Correct Answer is C

Explanation

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.

A. Don an N95 respirator mask, face shield, gown, gloves, and shoe coverings prior to returning to the room. B. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. D. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility.

Correct Answer is A

Explanation

Choice A reason: Donning appropriate personal protective equipment (PPE) is the most important action to protect the healthcare provider and prevent the spread of the virus while caring for the client.

Choice B reason: Explaining to the client to inform others about potential exposure is important but can be done after ensuring the nurse's safety with proper PPE.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance is important for preventing the spread of the virus but is not the immediate priority.

Choice D reason: Notifying the charge nurse about the need for assignment to a COVID-19 specified area is necessary for infection control but follows the immediate action of donning PPE.

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A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer is C

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

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