The nurse is completing the admission assessment of an adolescent client who is underweight and admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

Reference Range:

Potassium (K+) [3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L]

White Blood Cell (WBC) [5000 to 10,000/mm3 or 5 to 10 x 109/L]

Body mass index of 21.

Blood pressure of 110/70 mm Hg.

Potassium level of 2.9 mEq/dl (2.9 mmol/L).

WBC of 10,000/mm3 (10 x 109/L).

Answer and Explanation

The Correct Answer is C

Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.

Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.

Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.

Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.

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Correct Answer is C

Explanation

Choice A rationale: Involving her in group therapy may be premature, as the client has just started to exhibit changes in behavior. Continuous observation is necessary to assess the nature and sustainability of these changes.

Choice B rationale: Praising her for the new behavior is positive, but continuous observation is essential to monitor for any signs of escalating or problematic behavior.

Choice C rationale: Observing her actions continuously is the most appropriate action at this point. The nurse needs to monitor the client closely to assess the nature of the changes, ensuring they are not indicative of increased agitation or potential harm.

Choice D rationale: Offering her a choice of activities may be appropriate once the nurse has a better understanding of the clien's current state. However, continuous observation is the priority.

A. Tell me what you think should happen. B. What do you think you should do? C. How serious was the collision? D. Call for transportation to the hospital.

Correct Answer is D

Explanation

Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.

Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.

Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.

Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

Correct Answer is C

Explanation

The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

Correct Answer is D

Explanation

A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

During a high school class on substance abuse, a student tells the group, "If I tried cocaine, I know I could handle it. I know when to stop." Which response is best for the nurse to provide?

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?