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 ["A","B","D"]

Explanation

Choice A reason: The sedimentation rate (ESR) is a common test used to detect inflammation associated with conditions such as rheumatoid arthritis. An elevated ESR indicates the presence of inflammation in the body.

Choice B reason: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis and are useful in confirming the diagnosis. The presence of these antibodies can help distinguish RA from other inflammatory conditions.

Choice C reason: D-Dimer is primarily used to rule out thrombotic conditions such as deep vein thrombosis and pulmonary embolism. It is not specifically related to the diagnosis or management of rheumatoid arthritis.

Choice D reason: C-reactive protein (CRP) is another marker of inflammation that is often elevated in rheumatoid arthritis. It provides information about the level of inflammation and can be used to monitor disease activity and response to treatment.

Choice E reason: While a white blood cell count can provide general information about infection or inflammation, it is not specific to rheumatoid arthritis and is not as useful as the other tests mentioned for diagnosing or managing RA.

A. Put a pillow under the buttocks. B. Apply a cold pack to the scrotal and penile areas. C. Obtain a specimen for urinalysis. D. Remove the indwelling urinary catheter. E. Notify the healthcare provider immediately.

Correct Answer is ["B","E"]

Explanation

Choice A reason: Elevating the buttocks with a pillow is not specifically indicated in the scenario provided. While it might assist in other situations to reduce swelling by using gravity, it isn't a standard intervention for the described situation post-TURP.

Choice B reason: Applying a cold pack to the scrotal and penile areas can help reduce the swelling and discomfort associated with edema. Cold therapy is effective in constricting blood vessels and reducing inflammation, making it an appropriate immediate intervention.

Choice C reason: While obtaining a urinalysis might provide information on the presence of infection or other abnormalities, it does not directly address the immediate issue of the observed edema. Therefore, it is not a primary intervention in this scenario.

Choice D reason: Removing the indwelling urinary catheter without specific orders can lead to complications and is not advised as an initial intervention. The catheter serves a critical purpose post-surgery and should be handled according to protocol or provider direction.

Choice E reason: Notifying the healthcare provider immediately is crucial when unexpected postoperative complications such as edema occur. Prompt communication allows for timely medical intervention and ensures that the patient receives the necessary care.

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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

Correct Answer is ["A","B","D"]

Explanation

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","E"]

Explanation

The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

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The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

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