During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?
Family history of schizophrenia.
History of suicide attempts.
Undiagnosed social anxiety symptoms (SAD).
Feelings of disorientation.
The Correct Answer is B
A. Family history of schizophrenia is relevant but not immediately critical.
B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.
C. Social anxiety symptoms are important but not as critical as addressing suicide risk.
D. Disorientation needs assessment but is not as urgent as managing suicide risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Past experience with similar problems can provide useful insights but should not be the sole basis for evidence-based decision-making.
B. Related personal values may influence the nurse's perspective, but evidence-based practice should be grounded in objective, empirical data rather than personal beliefs.
C. The relevance of the evidence to the situation is most important. Evidence must be directly applicable to the clinical question and problem at hand to ensure the decision-making process is appropriate and effective.
D. The frequency that the problem occurs can help prioritize issues but does not necessarily impact the quality or applicability of the evidence gathered.
Correct Answer is ["B","D","E"]
Explanation
A. Standard precautions are important, but VRE requires contact precautions due to its highly transmissible nature. A mask is not specifically required unless there are respiratory symptoms.
B. Contact precautions are essential for preventing the spread of VRE and should be instituted for staff and visitors.
C. A low bacteria diet is not necessary for VRE infections; it is more relevant for immunocompromised patients.
D. Monitoring the white blood cell count helps assess the infection's progression and the body's response.
E. Sending wound drainage for culture and sensitivity is crucial for identifying the specific pathogen and determining appropriate antibiotic treatment.
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