The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?
Check the client's level of consciousness.
Determine the depth of the slashes.
Estimate the amount of blood loss.
Find the object used to cause the injuries.
The Correct Answer is A
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.
Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B) Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C) Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D) Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.
Correct Answer is C
Explanation
Orlistat is a weight-control medication that works by inhibiting the absorption of dietary
fats in the intestines. It can also interfere with the absorption of fat-soluble vitamins (such as vitamins A, D, E, and K) and beta-carotene. Therefore, it is important for the client to take a multivitamin supplement to ensure an adequate intake of these essential nutrients.
However, it is recommended to take the multivitamin and orlistat at least two hours apart. This is because orlistat can potentially interfere with the absorption of the
fat-soluble vitamins in the multivitamin if taken simultaneously. By spacing them apart, the client can optimize the absorption of both the medication and the multivitamin.
Multivitamins are not contraindicated during treatment with orlistat. In fact, they are often recommended to compensate for potential nutrient deficiencies.
While orlistat may contain some vitamins and minerals, it does not provide all the recommended daily amounts. Therefore, additional supplementation may be necessary. While following a well-balanced diet is indeed important for good nutrition, it does not address the need for specific nutrient supplementation when taking orlistat. Both a balanced diet and appropriate vitamin supplementation can be beneficial in this situation.
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