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.

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Correct Answer is D

Explanation

Rationale:

A. Mix the medication in juice prior to administration: Montelukast can be mixed with soft foods like applesauce, but mixing it in juice is not specifically recommended due to potential taste masking and dosing accuracy issues. Instructions should follow the manufacturer’s guidelines.

B. Administer the medication when the toddler has an acute asthma attack: Montelukast is a maintenance medication used to prevent asthma symptoms and is not effective for treating acute asthma attacks. A rescue inhaler like albuterol should be used during acute episodes.

C. Provide an additional dose of the medication prior to physical activity: Montelukast is not typically dosed in response to physical activity. While it can help prevent exercise-induced bronchospasm, it should be taken once daily in the evening, not additionally before exertion.

D. Administer the medication to the toddler each evening: Montelukast is prescribed as a once-daily maintenance therapy and is most effective when given in the evening. This helps maintain consistent blood levels and prevents nighttime asthma symptoms.

A. 1/2 cup of corn B. 1/2 cup of cooked lentils C. 1 fried egg D. 1 slice of toast

Correct Answer is B

Explanation

Rationale:

A. 1/2 cup of corn: While corn contains some folate, the amount is relatively low compared to legumes and leafy greens. It is not considered one of the best sources of folic acid for meeting the increased demands of early pregnancy.

B. 1/2 cup of cooked lentils: Lentils are among the richest natural sources of folic acid, providing a significant portion of the recommended daily intake. They are especially beneficial during early pregnancy to help prevent neural tube defects in the developing fetus.

C. 1 fried egg: Eggs provide a small amount of folate but are not a primary source. Although eggs offer other important nutrients during pregnancy, they do not meet the body’s high folic acid needs at 8 weeks gestation.

D. 1 slice of toast: Most bread products in some regions are fortified with folic acid, but the quantity in a single slice is minimal. While it can contribute to daily intake, it is not as concentrated a source as legumes like lentils.

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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 the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about foods that are high in folic acid with a client who is at 8 weeks of gestation. Which of the following foods should the nurse recommend as the best source of folic acid?

Correct Answer is B

Explanation

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