A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?

Determine triage level and examine and stabilize as needed.

Give the patient information about facilities that specialize in treating people without health insurance.

Ask the patient to sign in and provide method of payment for services.

Transfer the patient to a hospital that specializes in traumatic brain injuries.

Answer and Explanation

The Correct Answer is A

The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.

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Correct Answer is ["B","D","E"]

Explanation

The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.

Option A is incorrect because irrational fear of certain objects is more indicative of a phobia than OCD.

Option C is incorrect because clients with OCD are usually aware of their compulsions and may even try to resist them.

Reasons why the other options are not correct answers:

Option A: Irrational fear of certain objects is more indicative of a phobia than OCD.

Option C: Clients with OCD are usually aware of their compulsions and may even try to resist them.

A. "You are probably right. Soiling the bed is a way of getting attention from the nursing staff." B. "Tell me what makes you feel the client is doing this on purpose?" C. "Why don't you spend more time with the client if you think that she is trying to get attention?" D. "Next time this happens, tell me and I'll talk to the client about his behavior."

Correct Answer is B

Explanation

When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.

Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.

Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.

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A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?

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Naxlex Comprehensive Predictor Exams

The nurse is collecting data from a client with obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

Correct Answer is B

Explanation

The mortality rate for burns is highest in the elderly population. What factors put the very elderly at a high risk? (Select all that apply.)

A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?