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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Encourage the client to take sips of diluted fruit juice: Offering small amounts of juice may help introduce oral intake gradually, but it is not the first step. Ensuring the client can safely swallow is essential before providing any oral fluids to prevent aspiration and other complications.

B. Give the client a pureed diet: Transitioning to a pureed diet is part of advancing nutrition after confirming that the client can swallow safely. Starting this too early without assessing swallowing ability can increase the risk of choking or aspiration.

C. Check the client's swallowing reflex: Assessing the swallowing reflex is the priority when tapering a client from TPN. Safe oral intake depends on intact swallowing function, and identifying any deficits early prevents aspiration, aspiration pneumonia, or other serious complications during the transition to oral nutrition.

D. Provide the client with a full liquid diet: A full liquid diet is a step in progressing from TPN to oral intake, but it should only be introduced after confirming the client can swallow safely. Skipping the assessment of the swallowing reflex could place the client at risk for airway compromise.

A. Capillary refill less than 2 seconds B. Bilateral brachial pulses +3 C. Blood return from IV site catheter D. Dark streak at the vein of the insertion site

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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