A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Urinary retention

Blurred vision

Headache

Bradypnea

Answer and Explanation

The Correct Answer is D

Choice A reason:

Urinary retention can be a side effect of both diazepam and hydromorphone, but it is not typically life-threatening. While it should be monitored and addressed, it is not the most urgent concern compared to respiratory issues.

Choice B reason:

Blurred vision can occur with the use of diazepam and hydromorphone, but it is generally not an immediate threat to the client’s life. It should be reported and managed, but it is not the highest priority.

Choice C reason:

Headache is a common side effect of many medications, including diazepam and hydromorphone. While it can be uncomfortable and may need treatment, it is not usually a sign of a life-threatening condition.

Choice D reason:

Bradypnea, or slow breathing, is a serious side effect that can occur with the use of both diazepam and hydromorphone, as both medications depress the central nervous system. This can lead to respiratory depression, which is potentially life-threatening and requires immediate medical attention.

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

Explanation

Choice A reason:

Hallucinations, particularly if they are distressing or command hallucinations, can increase the risk of suicide attempts.

Choice B reason:

Depression is a major risk factor for suicide. Clients with a history of depression are at higher risk for attempting suicide again.

Choice C reason:

Delusions, especially those that are paranoid or persecutory, can contribute to suicidal thoughts and behaviors.

Choice D reason:

Catatonia, a state of psychomotor disturbance, can be associated with severe depression and increase the risk of suicide.

Choice E reason:

Tinnitus, while distressing, is not typically a direct risk factor for suicide attempts. It may contribute to overall distress but is not a primary indicator of suicide risk.

A. “I agree with you. I’m sure this will never happen again.” B. “This is awful. You should file charges against your partner.” C. “This is clearly child endangerment. I will have to call the police.” D. “I’d like to know more about what happened. Let’s sit and talk.”

Correct Answer is D

Explanation

Choice A reason:

Agreeing with the parent and assuming the situation will not happen again is not appropriate. It dismisses the potential risk to the child and does not address the seriousness of the situation.

Choice B reason:

Telling the parent to file charges against their partner is a strong directive that may not be appropriate without further understanding of the situation. It is important to gather more information before making such recommendations.

Choice C reason:

Stating that the situation is clearly child endangerment and immediately calling the police may escalate the situation without fully understanding the context. It is important to assess the situation thoroughly before taking such actions.

Choice D reason:

Expressing a desire to know more about what happened and offering to talk is an appropriate response. It allows the nurse to gather more information, assess the situation, and provide support to the parent and child.

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A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt? (Select all that apply.)

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

Explanation

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child’s parent states, “My partner got fired today and came home angry. I don’t think this will happen again.” Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a newly admitted client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for this condition?

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A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?