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.

Answer and Explanation

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.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.

Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.

Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.

Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.

Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

A. Use standard precautions and wear a mask. B. Explain the purpose of a low bacteria diet. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Monitor the client's white blood cell count.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Standard precautions, including the use of masks, are essential to prevent the spread of MRSA, which can be transmitted through respiratory droplets.

Choice B reason: A low bacteria diet is not typically required for MRSA or osteomyelitis management and does not directly impact the treatment or prevention of infection spread.

Choice C reason: Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces.

Choice D reason: Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment.

Choice E reason: Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

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The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

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While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?