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: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.

Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.

Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.

Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.

A. Walt for the client to respond. B. Ask if the client heard the question. C. Ask a different question. D. Return at a later time to talk.

Correct Answer is A

Explanation

Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.

Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.

Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.

Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is C

Explanation

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

Correct Answer is A

Explanation

Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?

A client with chronic alcoholism receives a prescription for disulfiram. Which client statement indicates that this medication teaching has been effective?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?