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.

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A. Remove the PICC line. B. Measure the circumference of both upper arms. C. Notify the provider who inserted the PICC line. D. Apply a cold pack to the client's upper arm.

Correct Answer is B

Explanation

Rationale:

A. Removing the PICC line should only be done if directed by a provider after further assessment.

B. The first action is to measure the circumference of both arms to assess for possible complications such as thrombosis or infiltration. This measurement will help determine the extent of the swelling and inform subsequent actions.

C. Notifying the provider is important but should be done after gathering relevant assessment data, such as the arm circumference.

D. Applying a cold pack may be appropriate for reducing swelling but is not the first step. Assessment should come first.

A. Cognitive behavioral therapy B. Deep-brain stimulation C. Electroconvulsive therapy D. Vagal nerve stimulation

Correct Answer is A

Explanation

Rationale:

A. Cognitive behavioral therapy (CBT) is a noninvasive, evidence-based treatment for depression. It helps clients identify and change negative thought patterns and behaviors that contribute to their depression.

B. Deep-brain stimulation is an invasive procedure used for treatment-resistant depression and other neurological conditions.

C. Electroconvulsive therapy (ECT) is a noninvasive but more intensive treatment often used for severe or treatment-resistant depression. However, it is generally not the first line of treatment.

D. Vagal nerve stimulation is a more invasive treatment, typically reserved for cases where other treatments have failed.

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has depression. Which of the following noninvasive treatments should the nurse recommend to the client?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct?

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

A nurse is caring for a client who has schizophrenia and diabetes mellitus. The nurse is reviewing a list of the client's prescribed medications and has questions about interactions. To which of the following members of the interprofessional team should the nurse direct their questions?

A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa?

A nurse is planning care for a client who has chronic substance use disorder. Which of the following is the most therapeutic response to help the client cease alcohol consumption?

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