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 A
Explanation
A. The client started working in a parking garage 3 months ago: Working in a parking garage can increase exposure to carbon monoxide and other exhaust fumes, which can be harmful to both the pregnant client and the fetus. Prolonged inhalation of these toxins may reduce oxygen delivery and contribute to complications, making this finding a priority for further evaluation.
B. The client is doing 30 min of moderate exercise daily: Moderate exercise is recommended during pregnancy as it improves circulation, reduces stress, and supports healthy weight gain. This behavior is considered safe and beneficial unless otherwise contraindicated by the provider.
C. The client is drinking 2.5 L of water per day: Adequate hydration is essential during pregnancy to support amniotic fluid levels, circulation, and kidney function. A daily intake of 2.5 liters is appropriate and aligns with recommended guidelines for pregnant clients.
D. The client last visited the dentist 4 months ago: Routine dental care is important during pregnancy due to increased risk of gingivitis, but a dental visit 4 months ago does not indicate an unsafe behavior. Continuing regular appointments every 6 months is generally sufficient unless specific concerns arise.
Correct Answer is D
Explanation
A. BUN 22 mg/dL (10 to 20 mg/dL): A slightly elevated BUN indicates mild renal impairment or dehydration but does not typically require withholding enoxaparin. Monitoring renal function is important, but this value alone is not a contraindication for anticoagulation.
B. WBC count 15,000/mm3 (5,000 to 10,000/mm3): An elevated WBC suggests possible infection or inflammation. While it may warrant further assessment, it does not directly increase the risk of bleeding and is not a reason to withhold enoxaparin.
C. Urine specific gravity 1.04 (1.005 to 1.03): A high specific gravity may indicate dehydration but is not a contraindication for enoxaparin administration. The medication can be given with caution while monitoring renal function and fluid status.
D. Platelets 80,000/mm3 (150,000 to 400,000/mm3): Thrombocytopenia significantly increases the risk of bleeding while on enoxaparin, which is an anticoagulant. Withholding the dose and notifying the provider is essential to prevent hemorrhagic complications and ensure safe management of the client.
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