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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect- The left lateral position might not provide enough lung expansion for a client in respiratory distress.
B) Incorrect- Reverse Trendelenburg (head of bed elevated, foot of bed lowered) might not provide enough lung expansion and could exacerbate respiratory distress.
C) Correct- The High-Fowler's position, where the client is sitting upright at a 90-degree angle or as upright as tolerated, helps to improve lung expansion, reduce pressure on the diaphragm, and promote optimal oxygenation. This position is commonly used for clients with respiratory distress.
D) Incorrect- The supine position may worsen pulmonary congestion and compromise lung expansion in clients with pulmonary edema.

A. Level of consciousness B. Capillary refill C. Temperature D. Blood pressure F. Pupil size and reactiveness G. Skin turgor H. Heart rate

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

Explanation

Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.

Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.

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The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

Correct Answer is C

Explanation

Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.

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

Explanation

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