An adult client with severe depression was admitted to the psychiatric unit yesterday evening.

Despite having run a marathon a year ago, the client now spends most of the day sitting and watching television, according to the spouse.

What is the most important intervention for the nurse to include in this client’s care plan for today?

Encourage the client to participate in a team sport for one hour.

Assist the client in developing a list of daily affirmations.

Schedule the client for a group session that focuses on self-esteem.

Help the client in identifying goals for the day.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.

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Correct Answer is C

Explanation

Choice A rationale
Monitoring the patient’s blood pressure every 1 hour for 2 hours after paracentesis may not be sufficient. Paracentesis is a procedure to remove fluid that has accumulated in the abdominal cavity (a condition called ascites). This is a common problem in people with certain diseases, including liver and kidney disease. Changes in blood pressure can occur rapidly after this procedure, so more frequent monitoring is needed immediately after the procedure.
Choice B rationale
Monitoring the patient’s blood pressure every 5 minutes for one hour after paracentesis may be too frequent and could cause unnecessary stress for the patient. It is important to balance the need for monitoring with the patient’s comfort and well-being.
Choice C rationale
Monitoring the patient’s blood pressure every 15 minutes for one hour, then every 1 hour for 2 hours after paracentesis is a good schedule. This allows for close monitoring immediately after the procedure, when complications are most likely to occur. It then allows for continued monitoring as the patient stabilizes.
Choice D rationale
Monitoring the patient’s blood pressure every 5 minutes for 30 minutes, then every 4 hours thereafter may not provide enough monitoring in the immediate post-procedure period. While it is important to continue monitoring, the first few hours after the procedure are a critical time when complications are most likely to occur.

A. Offer the client oral fluids. B. Feed the client a snack. C. Assess the breath sounds. D. Empty the urinary drainage bag.

Correct Answer is D

Explanation

Choice A rationale
Offering the client oral fluids is important for hydration, but it may not be appropriate for all patients, especially those with certain medical conditions or those who are NPO (nothing by mouth)7.
Choice B rationale

Feeding the client a snack can help maintain energy levels, but it may not be appropriate for all patients, especially those with dietary restrictions or those who are NPO7.
Choice C rationale
Assessing breath sounds is an important part of respiratory assessment, but it is not typically within the scope of practice for unlicensed assistive personnel (UAP). This task should be performed by a licensed nurse.
Choice D rationale
Emptying the urinary drainage bag is an appropriate task for a UAP to perform each time the client is turned. This helps ensure accurate measurement of urinary output and prevents infection by keeping the bag below the level of the bladder.

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Naxlex Comprehensive Predictor Exams

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

Correct Answer is C

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to perform each time the client is turned?

Correct Answer is D

Explanation

The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma. The adolescent reports experiencing phantom limb pain. Which non-pharmacological intervention should the nurse provide?

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

The nurse is preparing a dose of teriparatide for a patient. The medication is labeled as “750 mcg/2.4 mL”. How many mL should the nurse administer to deliver a dose of 60 mcg

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?