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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Adequate hydration: Maintaining proper fluid intake helps reduce blood viscosity and prevents sickling of red blood cells. Dehydration is a common trigger for sickle cell crises, so emphasizing hydration is crucial for prevention.
B. Increased iron intake: Most clients with sickle cell anemia do not require additional iron unless they have documented iron deficiency. Excess iron can accumulate and cause complications, especially in those receiving frequent transfusions.
C. Calorie restriction: Restricting calories is not recommended, as children with sickle cell anemia often have increased metabolic needs due to chronic hemolysis and may require adequate nutrition for growth and energy.
D. A low-protein diet: Protein is important for growth, tissue repair, and overall health. A low-protein diet is not indicated and could worsen nutritional status in children with sickle cell disease.
Correct Answer is ["140"]
Explanation
Calculation:
- Convert the client's current weight from kilograms (kg) to pounds (lbs).
Current weight (lbs) = Patient weight (kg) x Conversion factor (lbs/kg)
= 75 kg x 2.2 lbs/kg
= 165 lbs.
- Calculate the total weight loss over 25 weeks.
Total weight loss (lbs) = Weight loss per week (lbs) x Number of weeks
= 1 lb/week x 25 weeks
= 25 lbs.
- Calculate the expected goal weight in pounds (lbs).
Goal weight (lbs) = Current weight (lbs) - Total weight loss (lbs)
= 165 lbs - 25 lbs
= 140 lbs.
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