Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Administer ondansetron to the client for nausea.

Obtain a blood glucose level.

Implement seizure precautions for the client.

Obtain the client's weight

Answer and Explanation

The Correct Answer is C

Rationale:

A. Administer ondansetron to the client for nausea: Treating nausea is important for comfort, but it does not address the most urgent risk. Nausea is not immediately life-threatening compared with potential complications from medication overdose.

B. Obtain a blood glucose level: Checking blood glucose can provide useful information, but there is no indication of hypoglycemia or diabetes-related crisis in this scenario. It is not the priority action.

C. Implement seizure precautions for the client: The client has been doubling the bupropion dose, which significantly increases the risk of seizures, especially at doses above the prescribed maximum. Seizure precautions address an immediate life-threatening risk and should be the first intervention.

D. Obtain the client's weight: Monitoring weight is important for assessing nutritional status and the severity of depression, but it is not an immediate safety concern. Life-threatening risks, such as seizures, take priority.

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Correct Answer is B

Explanation

A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.

B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.

C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.

D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.

A. Document the client's level of understanding about potential adverse effects. B. Determine the client's knowledge about diaphragm use. C. Supervise return demonstration of diaphragm use. D. Teach the client how to insert the diaphragm.

Correct Answer is B

Explanation

A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.

B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.

C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.

D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.

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Exhibits A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)