A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?

“How do you get along with your peers at school?”

“Do you have a criminal record?”

“Do you have thoughts of harming yourself?”

“How do you manage your behavior?”

Answer and Explanation

The Correct Answer is C

This is the priority question for the nurse to ask the client because it assesses the client’s risk for suicide, which is a serious and potentially life-threatening complication of conduct disorder. The nurse should use a direct and nonjudgmental approach when asking about suicidal ideation and plan.

Choice A is wrong because it is not the most urgent question to ask the client.

While it is important to assess the client’s social relationships and possible peer rejection, this can be done after addressing the client’s safety and mental status.

Choice B is wrong because it is not relevant to the client’s current condition and might make the client feel defensive or stigmatized.

The nurse should avoid asking questions that imply blame or judgment and focus on the client’s strengths and coping skills.

Choice D is wrong because it is not appropriate for the nurse to ask the client in an emergency department setting.

This question might imply that the client is responsible for their conduct disorder, which is a complex and multifactorial mental health condition. The nurse should collaborate with the client and their family to develop a behavior management plan that involves positive reinforcement, limit setting, and consistent consequences.

Normal ranges: According to the DSM-5, conduct disorder is characterized by a persistent pattern of behavior that violates the rights of others or societal norms.

The symptoms of conduct disorder include aggression, deceitfulness, destruction of property, serious rule violations, and lack of remorse.

Conduct disorder can cause significant impairment in social, academic, or occupational functioning. The prevalence of conduct disorder is estimated to be 4% among children and adolescents.

The risk factors for conduct disorder include genetic factors, neurobiological factors, environmental factors, and psychological factors.

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Correct Answer is ["A","B","C","D","H"]

Explanation

A. Heart rate: The client’s heart rate is elevated at 118/min, which could indicate blood loss, dehydration, pain, anxiety, or infection. This finding requires immediate follow-up to assess the cause and intervene as needed.
B. Current medications: The client is taking ibuprofen 800 mg three times daily PRN for arthritis pain. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation, ulceration, and bleeding. This finding requires immediate follow-up to evaluate the client’s pain level, medication use, and possible alternatives to NSAIDs.
C. Blood pressure: The client’s blood pressure is low at 90/50 mm Hg, which could indicate hypovolemia, shock, or cardiac dysfunction. This finding requires immediate follow-up to monitor the client’s fluid status, perfusion, and organ function.
D. Stool results: The client’s stool tested positive for occult blood and H. pylori bacteria. Occult blood indicates gastrointestinal bleeding, which could be related to the client’s abdominal pain and weight loss. H. pylori is a common cause of peptic ulcer disease, which can also cause bleeding and pain. This finding requires immediate follow-up to confirm the diagnosis and initiate treatment with antibiotics and acid-suppressing drugs.

H. Hemoglobin and hematocrit: The client’s hemoglobin and hematocrit are low at 9.1 g/dL and 27%, respectively. These values indicate anemia, which could be caused by chronic blood loss, nutritional deficiency, or bone marrow suppression. This finding requires immediate follow-up to determine the etiology and severity of the anemia and provide appropriate therapy such as blood transfusion, iron supplementation, or erythropoietin.

The other findings are not as urgent as the ones above:

E. Respiratory rate: The client’s respiratory rate is normal at 18/min. There is no evidence of respiratory distress or hypoxia.
F. WBC count: The client’s WBC count is normal at 6,700/mm3. There is no indication of infection or inflammation.
G. Temperature: The client’s temperature is slightly elevated at 37.5° C (99.5° F), but not enough to warrant immediate concern. It could be due to stress, dehydration, or a mild infection. The nurse should monitor the temperature trend and report any significant changes or signs of sepsis.

A. Epigastric pain. B. Hypertension. C. Contractions. D. Vomiting.

Correct Answer is C

Explanation

According to the flashcards from Quizlet, a nurse should monitor a client who is at 33 weeks of gestation following an amniocentesis for contractions, as they are a sign of preterm labor and possible uterine rupture. An amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for testing. It can cause complications such as bleeding, infection, leakage of fluid, and injury to the fetus or placenta.

Choice A is wrong because it is not a common complication of amniocentesis.

Epigastric pain is more likely to be associated with preeclampsia, a condition that causes high blood pressure and proteinuria in pregnancy. Epigastric pain can indicate severe preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which are life- threatening complications that require immediate medical attention.

Choice B is wrong because it is not a direct result of amniocentesis.

Hypertension can occur in pregnancy due to various factors, such as chronic hypertension, gestational hypertension, preeclampsia, or eclampsia. Hypertension can increase the risk of complications such as placental abruption, fetal growth restriction, preterm birth, and maternal stroke.

Choice D is wrong because it is not a typical complication of amniocentesis.

Vomiting can occur in pregnancy due to various causes, such as morning sickness, gastroenteritis, food poisoning, or hyperemesis gravidarum. Vomiting can lead to dehydration, electrolyte imbalance, weight loss, and malnutrition if not treated properly.

Some normal ranges that are relevant for this question are:

The normal gestational age for delivery is between 37 and 42 weeks.

A baby born before 37 weeks is considered preterm and may have complications such as respiratory distress syndrome, bleeding in the brain, infection, or low blood sugar.

The normal fetal heart rate is between 110 and 160 beats per minute.

A fetal heart rate below 110 or above 160 can indicate fetal distress or hypoxia.

The normal amniotic fluid index (AFI) is between 8 and 18 cm.

An AFI below 5 cm is considered oligohydramnios and can indicate fetal growth restriction, kidney problems, or rupture of membranes.

An AFI above 24 cm is considered polyhydramnios and can indicate fetal anomalies, diabetes mellitus, or Rh incompatibility.

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A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to the medical-surgical unit The clientreports, "I'm bloated and my stomach hurts." Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","D","H"]

Explanation

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

Correct Answer is C

Explanation

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