A client with depression is admitted to an inpatient psychiatric unit. The nurse provides a unit orientation. While observing the client's unpacking, the nurse can expect the client to exhibit:

A desire to initiate conversation with roommates.

Expansive and dramatic movements.

Decelerated movements and flat affect.

Overly excited interest in the admission.

Answer and Explanation

The Correct Answer is C

A. A desire to initiate conversation with roommates. Clients with depression typically withdraw socially and may not seek to initiate conversations or engage with others.

B. Expansive and dramatic movements. Expansive and dramatic movements are more characteristic of mania, not depression.

C. Decelerated movements and flat affect. Depression often leads to psychomotor retardation, where the client’s movements are slow and their affect is flat, showing a lack of emotional expression.

D. Overly excited interest in the admission. An overly excited interest would be inconsistent with the symptoms of depression, which often include a lack of interest or enthusiasm.

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Correct Answer is A

Explanation

A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.

B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.

C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.

D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.

A. Administer a saline enema for constipation. B. Initiate contact precautions. C. Encourage independence in the completion of ADLs. D. Monitor oral mucosa daily.

Correct Answer is D

Explanation

A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.

B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.

C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.

D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.

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A client with depression is admitted to an inpatient psychiatric unit. The nurse provides a unit orientation. While observing the client's unpacking, the nurse can expect the client to exhibit:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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