A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

"What coping methods help you when you feel bad?"

"Do you have thoughts of suicide?"

"Tell me why you hurt yourself."

"Who can we call to support you?"

Answer and Explanation

The Correct Answer is B

Rationale:

A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.

B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.

C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.

D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. "You should replace your diaphragm every 2 years": Diaphragms generally need to be replaced every 1 to 2 years, depending on the manufacturer’s guidelines and wear and tear. However, it is more important to be aware of refitting needs related to physiological changes.

B. "You should be refitted for your diaphragm if you have a 10 percent weight fluctuation.": Significant weight changes, usually around 10 to 15 percent, can alter pelvic anatomy and affect diaphragm fit, increasing the risk of contraceptive failure. Therefore, refitting is recommended after notable weight fluctuations.

C. "You should insert the diaphragm when your bladder is full.": The bladder should be empty when inserting the diaphragm to avoid discomfort and ensure proper placement over the cervix. A full bladder can cause displacement and increase the risk of failure.

D. "You should remove your diaphragm 4 hours after intercourse.": The diaphragm should be left in place for at least 6 hours after intercourse to ensure adequate sperm immobilization and contraceptive effectiveness. Removing it too early may increase the risk of pregnancy.

A. Boggy fundus 3 fingerbreadths above the umbilicus B. Client report of burning with urination C. Saturation of perineal pad in 15 min D. Client report of uterine cramping

Correct Answer is D

Explanation

Rationale:

A. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy uterus located above the umbilicus suggests uterine atony, which indicates that the oxytocin may not have been effective. This finding is not expected 30 minutes after administering oxytocin.

B. Client report of burning with urination: Burning during urination is unrelated to oxytocin administration and may point toward a urinary tract infection. It does not reflect the expected physiological response to uterine stimulation for controlling postpartum hemorrhage.

C. Saturation of perineal pad in 15 min: Continued excessive bleeding despite oxytocin administration indicates treatment failure and requires immediate intervention. Oxytocin should reduce uterine bleeding; thus, ongoing hemorrhage is not an expected finding.

D. Client report of uterine cramping: Uterine cramping is an expected response to oxytocin, which works by stimulating uterine smooth muscle contractions. These cramps help compress blood vessels at the placental site, reducing postpartum bleeding and promoting involution.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is using a diaphragm to prevent pregnancy. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following finding should the nurse expect?

Correct Answer is D

Explanation

A nurse is unfamiliar with a medication they are preparing to administer to a client. Which of the following actions should the nurse take?

A nurse in a prenatal clinic is reviewing the medical record of a client who is at 16 weeks of gestation to determine the need for immunizations. Which of the following prescriptions should the nurse anticipate?

A nurse is assisting in planning care for a 16-year-old client in a pediatric clinic. Which of the following actions would be a breach of confidentiality?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

A nurse is contributing to the plan of care for a newborn who has a temperature of 36.4° C (97.5° F) at 1 hr after birth. Which of the following interventions should the nurse include?

A nurse is reinforcing teaching about home safety needs for a toddler. Which of the following statements by the toddler's parents indicates an understanding of the teaching?

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdown as evidenced by the client's dropdown and dropdown.

A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching?