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 ["B","D","F"]
Explanation
A. Tape: While tape might be useful for securing the nasal cannula, it is not specifically required for starting oxygen therapy.
B. Flowmeter: A flowmeter is necessary to regulate and measure the flow rate of the oxygen being delivered to the client.
C. Lamb's wool: This is not related to oxygen therapy; it is used for other purposes like padding.
D. Nasal cannula: This is the device prescribed for delivering supplemental oxygen at 3 L/minute.
E. Sterile water: Sterile water is not typically required for starting oxygen therapy but may be used with certain humidification systems.
F. Humidifier bottle: When providing oxygen at higher flow rates, a humidifier bottle may be needed to prevent dryness of the nasal passages.
G. Suction cannister: This is used for suctioning and is not needed for administering oxygen.
Correct Answer is A
Explanation
A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.
B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.
C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.
D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.