Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night.
Which intervention is most important for the nurse to implement?
Ask the spouse if the client seems to be depressed.
Tell the spouse to wait outside so the client can be assessed for depression.
Explain that depression often occurs after a life-threatening experience.
Encourage the client to further describe his feelings.
The Correct Answer is D
A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restraints should be secure but not too tight to prevent injury or impaired circulation.
B. Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C. A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D. Restraints should never be tied to side rails as this can cause injury if the rails are moved.
Correct Answer is ["1.4"]
Explanation
To calculate the dosage of lorazepam for the client, first determine the total micrograms required by multiplying the client's weight in kilograms by the prescribed amount per kilogram. For a client weighing 65 kg prescribed 44 mcg/kg, the total dosage would be 65 kg x 44 mcg/kg, which equals 2860 mcg. Since the medication is available in a concentration of 2 mg/ml, convert the total dosage from micrograms to milligrams by dividing by 1000 (because there are 1000 micrograms in a milligram). This results in 2.86 mg. Finally, to find out how many milliliters to administer, divide the total milligrams needed by the concentration of the vial, which is 2 mg/ml. Therefore, 2.86 mg / 2 mg/ml equals 1.43 ml. When rounding to the nearest tenth, the nurse should administer 1.4 ml of lorazepam.
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