A nurse on a mental health unit is caring for four clients. Which of the following clients should the nurse see first?
A client who has schizophrenia and exhibits apathy
A client who has an anxiety disorder and appears restless
A client who has major depressive disorder and reports hopelessness
A client who has bipolar disorder and exhibits provocative behavior
The Correct Answer is C
A. A client with schizophrenia exhibiting apathy may require attention, but it may not be an immediate priority unless there are signs of deterioration or safety concerns.
B. A client with an anxiety disorder appearing restless may be experiencing distress, but it is not necessarily indicative of an immediate safety or crisis situation.
C. A client with major depressive disorder reporting hopelessness raises significant concern, as it may indicate an increased risk of self-harm or suicide. Clients expressing hopelessness should be assessed promptly to determine the level of risk and implement appropriate interventions.
D. A client with bipolar disorder exhibiting provocative behavior may pose a potential risk, but the level of urgency is typically higher for a client expressing hopelessness and depressive
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Complete an incident report.
Reporting a needlestick injury through an incident report is crucial. It documents the details of the incident, which is important for the nurse's safety and for initiating appropriate follow-up actions.
B. Receive a hepatitis C immunization:
There is no specific hepatitis C vaccine available. While there are vaccines for hepatitis A and hepatitis B, there is currently no vaccine to prevent hepatitis C. Seeking post-exposure prophylaxis and follow-up is more relevant in this case.
C. Notify the health department:
Notifying the health department might be necessary in some cases, but the immediate action for the nurse is to report the incident through an incident report within the facility. This allows for prompt internal investigation and necessary measures.
D. Start prophylactic antibiotic therapy:
Prophylactic antibiotic therapy is not the standard protocol for preventing hepatitis C transmission after a needlestick injury. Antiviral medications might be considered in certain cases for post-exposure prophylaxis for hepatitis C, but this decision should be made after consulting with a healthcare provider or infectious disease specialist based on the specific circumstances of the exposure. Reporting the incident remains the immediate priority.
Correct Answer is ["500"]
Explanation
To calculate the mL/hr for the lactated Ringer's IV infusion over 30 minutes, you can use the following formula:
Rate (mL/hr)=Volume (mL)/Time (hr)
In this case:
Rate=250 mL/ 0.5 hr
Rate=500mL/hr
Therefore, the nurse should set the IV pump to deliver 500 mL/hr for the lactated Ringer's IV infusion over 1 hour.
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