The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Initiate droplet precautions

Initiate airborne precautions

Place the client in a positive pressure room

Initiate neutropenic precautions

Answer and Explanation

The Correct Answer is B

B. Airborne precautions are used for diseases that can be transmitted through tiny respiratory droplets that remain in the air for extended periods. Examples include tuberculosis and measles. Given the symptom of coughing up blood and the possibility of an infectious respiratory disease, initiating airborne precautions could be warranted.
A. Droplet precautions are typically implemented for diseases that spread through respiratory droplets, such as influenza or pertussis. However, coughing up blood suggests a more serious condition that may not be adequately addressed by droplet precautions alone.
C. Positive pressure rooms are typically used in healthcare settings to prevent outside air from entering the room, thus reducing the risk of airborne contaminants. While this measure can be beneficial for certain conditions, such as those requiring airborne precautions, it may not be the priority intervention.
D. Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). While this precaution is important for protecting immunocompromised patients from infections, it may not be the priority intervention.

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Correct Answer is A

Explanation

A. Ginkgo biloba has been reported to have anticoagulant properties and may potentiate the effects of warfarin, increasing the risk of bleeding. Therefore, individuals taking warfarin should exercise caution when using ginkgo supplements and be monitored closely for signs of bleeding or changes in anticoagulant response.
B. Dandelion is not known to directly affect blood clotting or the action of warfarin.
C. Acai berry is a fruit commonly consumed for its potential antioxidant properties and health benefits. There is limited scientific evidence regarding the interaction between acai and warfarin.
D. Zinc supplementation is generally considered safe for most individuals and there is limited evidence to suggest that zinc significantly enhances the anticoagulant effects of warfarin.

A. Short, polite responses to interview questions B. Introspection related to present situation C. Feelings of helplessness and hopelessness D. Disorganized thinking and the inability to remain seated.

Correct Answer is D

Explanation

D. Mania is characterized by symptoms such as increased energy levels, decreased need for sleep, impulsivity, racing thoughts, and agitation. Disorganized thinking, rapid speech, and an inability to remain seated are common manifestations of manic symptoms.
A. Clients in a manic episode often exhibit rapid speech, tangential thinking, and may be overly talkative rather than providing short, polite responses.
B. Manic individuals typically exhibit heightened energy levels, impulsivity, and distractibility, making it challenging for them to engage in introspection or focus on the present situation. Instead, they may be preoccupied with grandiose ideas, racing thoughts, or engaging in excessive activities.
C. This response is more characteristic of individuals experiencing depressive episodes of bipolar disorder rather than manic episodes. During a depressive episode, individuals with bipolar disorder may experience profound feelings of sadness, hopelessness, and helplessness, along with symptoms such as fatigue, changes in appetite or weight, and sleep disturbances.

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The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who takes warfarin 10 mg PO daily and several herbal remedies. The nurse would be most concerned that the use of which herb would enhance the anticoagulant effects of warfarin?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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