On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?
What drugs the client used for the suicide attempt.
When the client last took drugs for bipolar disorder.
Whether the client ever attempted suicide in the past.
Which family member has the client's suicide note.
The Correct Answer is A
Choice A reason: Knowing the type and amount of drugs ingested is critical for immediate medical intervention and treatment.
Choice B reason: While important, the timing of the last dose for bipolar disorder is less urgent than the details of the suicide attempt.
Choice C reason: Past suicide attempts are relevant for a psychiatric evaluation but are not the immediate concern in an acute overdose situation.
Choice D reason: The location of the suicide note is less critical than the medical information needed to treat the client's overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.
Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.
Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.
Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.
Correct Answer is A,B,C,D,E
Explanation
Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit.
Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation.
Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action.
Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure.
Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.
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