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 C

Explanation

Rationale:

A. Ensure that each client has a living will on file prior to treatment: While advance directives are encouraged, clients have the right to choose whether to have one, and care cannot be delayed or denied if they do not.

B. Place copies of incident reports in clients' medical records: Incident reports are internal risk management tools and should not be placed in the medical record, as this could increase legal liability and compromise confidentiality.

C. Obtain personal professional liability insurance coverage: Having individual liability coverage provides additional protection beyond employer coverage, ensuring legal and financial support if malpractice claims arise.

D. Overestimate clients' acuity to prevent short staffing: Falsifying acuity levels is unethical and can result in disciplinary action or loss of license; staffing concerns should be addressed through proper administrative channels.

A. Apply pressure to the lacrimal punctum. B. Place the child in a sitting position. C. Instill the drops of medication. D. Pull the lower eyelid downward.

Correct Answer is B,D,C,A

Explanation

Rationale:

B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.

D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.

C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.

A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.

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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

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A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make?

Correct Answer is C

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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.)