A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse see first?
A client who is exhibiting flight of ideas
A client who refuses to attend group therapy
A client who is experiencing a moderate level of anxiety
A client who is having command hallucinations
The Correct Answer is D
A. A client who is exhibiting flight of ideas: Flight of ideas indicates pressured, rapid speech and distractibility often seen in mania. While this requires monitoring and support, it does not pose an immediate risk of harm to the client or others.
B. A client who refuses to attend group therapy: Refusal to attend therapy reflects a non-urgent behavioral issue. The client’s autonomy should be respected, and interventions can be planned after more urgent concerns are addressed.
C. A client who is experiencing a moderate level of anxiety: Moderate anxiety may cause discomfort and decreased coping, but it does not typically create an immediate threat to safety. The nurse can intervene with calming techniques and support in a timely manner.
D. A client who is having command hallucinations: Command hallucinations can instruct the client to harm themselves or others, representing an immediate safety risk. The nurse should assess this client first to implement interventions that prevent potential harm and ensure safety on the unit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Airborne: Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air, such as tuberculosis, measles, or varicella. Mononucleosis, caused by the Epstein-Barr virus, is not transmitted via airborne particles, so airborne precautions are unnecessary.
B. Droplet: Mononucleosis is primarily transmitted through saliva and close respiratory contact, such as kissing or sharing utensils. Droplet precautions—including wearing a mask when within close contact and practicing hand hygiene—help prevent the spread of infectious respiratory secretions to others in the healthcare setting.
C. Contact: Contact precautions are indicated for infections transmitted by direct or indirect contact with contaminated surfaces, such as MRSA or Clostridioides difficile. Since mononucleosis is spread via respiratory droplets and saliva, contact precautions alone are insufficient.
D. Protective environment: Protective environment precautions are used to protect immunocompromised clients from exposure to environmental pathogens. They are not necessary for clients with mononucleosis, as the concern is preventing transmission from the infected client, not protecting them from infection.
Correct Answer is ["C","E"]
Explanation
A. BUN: Blood urea nitrogen is a marker of renal function and is not directly affected by warfarin therapy. While renal function is important for overall medication safety, it does not guide warfarin dosing or anticoagulation monitoring.
B. Serum potassium: Potassium levels are important for cardiac and neuromuscular function but are not influenced by warfarin. Monitoring potassium is unrelated to evaluating the effectiveness or safety of warfarin therapy.
C. PT: Prothrombin time measures the extrinsic and common coagulation pathways, which are directly affected by warfarin. Checking PT before administration helps assess anticoagulation status and the risk of bleeding, allowing for appropriate dose adjustments.
D. Serum sodium: Sodium levels are critical for fluid balance and neurologic function but do not affect warfarin therapy or coagulation. Monitoring sodium is not necessary for safe administration of warfarin.
E. INR: International normalized ratio standardizes PT results to guide warfarin therapy safely. It provides a reliable measure of anticoagulation and bleeding risk, and checking INR before administering warfarin ensures the dose is appropriate for therapeutic anticoagulation.
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