The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours.

A client with schizophrenia who wants to stop taking the medications.

The parent of a child who was involved in a physical fight at school today.

A client diagnosed with depression who is experiencing sexual dysfunction.

Answer and Explanation

The Correct Answer is A

Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.

Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.

Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.

Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.

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Correct Answer is B

Explanation

Choice A reason: While it's important to know if the client can lie prone, this is not the most critical piece of information prior to an intravenous pyelogram.

Choice B reason: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.

Choice C reason: Knowing the last time the client had a bowel movement is less critical than knowing about potential allergies to the contrast dye.

Choice D reason: While it's important to know about medication schedules, the risk of an allergic reaction to the contrast dye is a more immediate concern that could affect the safety of the procedure.

A. Measure vital signs and telemetry pattern. B. Palpate and compare pedal pulse volumes. C. Measure post-procedure intake and output. D. Remove the dressing and observe the site.

Correct Answer is A

Explanation

Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.

Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.

Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.

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The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for an intravenous pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

Correct Answer is B

Explanation

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Correct Answer is A

Explanation

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A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

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