86 mm Hg

Oxygen saturation 99%

A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.

Statement regarding outlook on living

Statement related to feelings of sadness and anger.

Knowledge of expectations during group meetings.

Awareness of the therapist's role.

Statement related to use of pharmacological interventions.

Question Solution

Correct Answer : A,B,E

Rationales:

A. The client's statement, "I can't go on living without my child," indicates a potentially serious risk to their safety and well-being. This statement suggests that the client may be experiencing suicidal ideation or extreme despair, which requires immediate attention and intervention.

B. While sadness and anger are expected components of grief, the intensity of these feelings and their persistence need to be assessed for any signs of complicated grief or potential for self-harm. Addressing these emotions is critical to ensuring the client’s safety and providing appropriate support.

C. While understanding the expectations during group meetings is important for therapy, it is not as immediately critical as addressing the client's statements about their outlook on living and their medication adherence.

D. Knowledge about the therapist’s role is important for therapeutic alliance, but it is less urgent compared to addressing the client’s potentially dangerous outlook on living and their medication issues.

E. The client’s refusal to take the prescribed medication, with the belief that it "will not help," indicates a possible issue with medication adherence or effectiveness. This needs to be addressed to ensure that the client is receiving appropriate treatment for their mental health needs.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Report the incident to the other RNS on the shift. B. Agree to not report the incident if the coworker seeks treatment. C. Report the incident to the appropriate person in the chain of communication D. Agree to not report the incident if the coworker promises to report

Correct Answer is C

Explanation

Rationale:

A. Reporting the incident to other RNs on the shift does not ensure that the appropriate actions will be taken to address the issue.

B. Agreeing not to report the incident in exchange for the coworker seeking treatment is unethical and does not follow the correct reporting protocol.

C. Reporting the incident to the appropriate person in the chain of communication, such as a supervisor or nurse manager, is the correct course of action. This ensures that the situation is handled according to hospital policy and legal requirements, protecting patient safety and addressing the coworker's substance use disorder.

D. Agreeing not to report the incident if the coworker promises to report themselves is also unethical and fails to meet professional responsibilities.

A. The final 2 min B. The final 15 min C. The first 15 min D. The first 2 min

Correct Answer is C

Explanation

Rationale:

A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.

B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.

C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.

D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.

Free Nursing Test Bank

Correct Answer is C

Explanation

Correct Answer is C

Explanation

Quick Links

Resources

Free Nursing Test Bank

A staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

Correct Answer is C

Explanation

A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?

A nurse asks a client if they prefer to attend the morning or afternoon group therapy session. The nurse should identify that this as an example of which of the following ethical principles?

A nurse working in a community health center is speaking with a client who has a serious mental illness. The client states that they are unable to find employment and they do not understand why. Which of the following questions should the nurse ask? (Select all that apply.)

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

A nurse is caring for a client who is experiencing lack of sleep, lack of appetite, and difficulties with concentration. Which of the following types of dementia should the nurse expect this client to have?

A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

A nurse is caring for a client who has illness anxiety disorder. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. Which of the following client statements indicates that the client is experiencing traumatic grief?

Quick Links

Resources