Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
A. Identify support groups in the community for long-term treatment.
Referring the client to a mental health care provider for evaluation and treatment.
B. Assist the client to identify negative effects of chemical dependency.
This may be necessary but does not address the priority concern of suicidal risk.
C. Determine the presence and degree of suicidal risk.
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment
D. Refer client to mental health care provider for evaluation and treatment.
This is animportant intervention but is not the priority at this time. Assisting the client to identify the negative effects of chemical dependency
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.
choice A and referring the client to a mental health care provider for evaluation and treatment.
choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.
choice B may be necessary but does not address the priority concern of suicidal risk.
Similar Questions
A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
A. Hypotension
This is not an answer because hypotension is a later sign of shock 2.
B. Narrowing pulse pressure
Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.
C. Decreased level of consciousness
This is not an answer because a decreased level of consciousness is also a later sign of shock .
D. Anuria
This is not an answer because anuria, or the absence of urine production, is also a later sign of shock
Full Explanation
Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.
Choice A is not an answer because hypotension is a later sign of shock 2.
Choice C is not an answer because a decreased level of consciousness is also a later sign of shock.
Choice D is not an answer because anuria, or the absence of urine production, is also a later sign of shock
A patient with heart failure has met with their primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, which assessment should the nurse prioritize?
A. Oxygen saturation.
This may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness,
B. Blood pressure.
When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension.
C. Level of consciousness.
This may also be important but are not the priority assessment in this situation.
D. Assessment for nausea.
This may also be important but are not the priority assessment in this situation.
Full Explanation
When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension. Oxygen saturation, choice A, may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness, choice C, and assessment for nausea, choice D, may also be important but are not the priority assessments in this situation.
The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?
A. "I was monitoring my blood glucose every 3 to 4 hours."
This is an appropriate patient action, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management. Therefore, this is not an indication of further teaching.
B. "I had to stop my insulin."
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching.
C. "I called the doctor because of these symptoms."
This is an appropriate patient action, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management. Therefore, this is not an indication of further teaching.
D. None of the above.
Full Explanation
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching. Choices A and C are appropriate patient actions, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management.
Therefore, these are not indications for further teaching.