A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

"Can you tell me about the stresses in your life?"

"Has anyone in your family ever died by suicide?

“Do you have a plan for harming yourself?"

“Do you have someone to discuss your feelings with?"

Answer and Explanation

The Correct Answer is C

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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Correct Answer is C

Explanation

For a client with a prepregnancy BMI of 30.5, the acceptable weight gain during pregnancy would be around 11 to 20 pounds (5 to 9 kilograms) according to the guidelines set by the Institute of Medicine (IOM).

A. Hypotension B. Constipation C. Slurred speech D. New onset of hearing loss

Correct Answer is D

Explanation

Gentamicin is an aminoglycoside antibiotic that is known to have potential ototoxicity, which means it can cause damage to the inner ear and result in hearing loss. It is important for the nurse to monitor the client's hearing during gentamicin therapy and report any changes or symptoms of hearing loss promptly. Other adverse effects of gentamicin may include nephrotoxicity (kidney damage), so monitoring renal function is also essential.

Hypotension, constipation, and slurred speech are not typically associated with gentamicin use. However, it is important for the nurse to monitor the client for any adverse effects and report any concerning symptoms to the healthcare provider.

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A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include that which of the following is an acceptable weight gain for this client?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is D

Explanation

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