A nurse from a medical-surgical unit is assigned to an inpatient mental health unit. Which of the following clients should the charge nurse assign to the medical-surgical nurse?
A client who has depression and anxiety with an established plan of care
A client who is trying to engage in self-harm and does not understand why they cannot leave the facility
A client who is being discharged and needs information on substance abuse counseling
A client who has been placed in restraints and requires documentation every 15 min
The Correct Answer is A
A. A client who has depression and anxiety with an established plan of care: A medical-surgical nurse can safely care for a client with stable mental health conditions when a clear, established plan of care is in place. This client does not require constant psychiatric interventions, making it appropriate for assignment.
B. A client who is trying to engage in self-harm and does not understand why they cannot leave the facility: This client is high-risk and requires a nurse with specialized mental health training to implement safety measures and therapeutic interventions. Assigning this client to a medical-surgical nurse could compromise safety.
C. A client who is being discharged and needs information on substance abuse counseling: Discharge teaching and counseling for substance abuse require specialized knowledge and therapeutic communication skills typical of mental health nurses. A medical-surgical nurse may not have the expertise to provide adequate education and support.
D. A client who has been placed in restraints and requires documentation every 15 min: Clients in restraints require frequent monitoring, crisis intervention, and mental health expertise. This high-acuity situation is not appropriate for a nurse without psychiatric training.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client's high-density lipoprotein level has increased: While metformin can have minor effects on lipid metabolism, an increase in HDL is not the primary therapeutic goal or a direct measure of the medication’s effectiveness in managing type 2 diabetes.
B. The client's frequency of incontinence has decreased: Urinary incontinence is not a direct indicator of metformin effectiveness. Changes in incontinence may result from other conditions or medications and do not reflect glycemic control.
C. The client's HbA1c has decreased: A decrease in HbA1c indicates improved long-term blood glucose control, which is the primary goal of metformin therapy. Monitoring HbA1c over 2–3 months helps determine how effectively the medication is managing type 2 diabetes.
D. The client's iron level has increased: Iron levels are not affected by metformin and do not serve as a measure of its efficacy. Changes in iron would be related to dietary intake, absorption issues, or other medical conditions rather than glucose management.
Correct Answer is D
Explanation
A. Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion. This finding does not suggest a complication of IV therapy and reflects proper circulation in the extremity.
B. Bilateral brachial pulses +3: Strong, equal pulses in both arms indicate normal arterial blood flow. This is not indicative of IV complications and shows the limb is well perfused.
C. Blood return from IV site catheter: Blood return from the IV catheter confirms proper placement within the vein. This is an expected finding and does not signal a complication.
D. Dark streak at the vein of the insertion site: A dark streak along the vein suggests infiltration, phlebitis, or early thrombophlebitis. This indicates a complication of IV therapy and requires immediate assessment, site removal or rotation, and appropriate interventions to prevent further tissue damage.
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