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 D

Explanation

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

A. hyperactivity and attention deficits. B. failure to develop interpersonal skills. C. high levels of anxiety when separated from the mother. D. a history of disobedience and destructive acts.

Correct Answer is B

Explanation

B. Children with ASD may show reduced interest in social interactions, have difficulty understanding social cues, and may not engage in typical play with peers or caregivers. They might also exhibit challenges with nonverbal communication, such as making eye contact or using gestures.
A. While hyperactivity and attention deficits can be present in children with ASD, they are not as specific to the diagnosis as impaired social skills.
C. High levels of anxiety when separated from the mother could be seen in many conditions and are not particularly indicative of ASD.

D. A history of disobedience and destructive acts could be seen in many conditions and are not particularly indicative of ASD.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

Correct Answer is D

Explanation

When assessing a 2-year-old child with suspected autism spectrum disorder, the nurse should be particularly alert for:

Correct Answer is B

Explanation

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