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

Rationale:

A. Abdominal pain: While abdominal pain can occur with peritonitis, it often develops after the initial changes in the dialysate effluent. Pain may also be related to catheter placement or dialysate temperature, so it is not the earliest definitive indicator.

B. Cloudy effluent: Cloudy dialysate is typically the first and most reliable sign of peritonitis in clients receiving peritoneal dialysis. It indicates the presence of white blood cells and infection in the peritoneal cavity before systemic symptoms appear.

C. Nausea: Nausea may occur later as part of the systemic inflammatory response, but it is nonspecific and can be caused by multiple factors, including the dialysis process itself or other gastrointestinal disturbances.

D. Fever: Fever is a later manifestation of peritonitis, often developing after local signs are present. It indicates systemic involvement and immune activation but is not the earliest detectable change.

A. Tell the client, "You seem to be very upset." B. Use a face shield with a mask when providing care to the client. C. Initiate seclusion protocol. D. Engage the panic alarm.

Correct Answer is A

Explanation

A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.

B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.

C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.

D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.

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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 assessing a client who is receiving peritoneal dialysis for manifestations of peritonitis. Which of the following findings should the nurse identify as the first indication of peritonitis?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Correct Answer is A

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.)