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.)
"What is your expected salary range?"
"Have you served time in prison?"
"What type of vehicle do you drive?"
"Do you use drugs?"
"Are you taking antipsychotic medication?"
Correct Answer : B,D,E
Rationale:
A. Asking about salary range is not directly relevant to the client’s mental health condition and would not help in understanding the barriers to employment.
B. Inquiring if the client has served time in prison may reveal a history that could impact their employability, as some employers may have restrictions on hiring individuals with criminal records.
C. Asking about the type of vehicle the client drives is not directly related to the client’s mental health or barriers to employment, and it would not provide insight into why the client is struggling to find work.
D. Asking about drug use is pertinent as substance abuse can interfere with employment opportunities and overall functioning.
E. Knowing whether the client is taking antipsychotic medication is important because adherence to treatment can significantly affect the client’s ability to function in a work environment.
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Correct Answer is A
Explanation
Rationale:
A. Stopping the transfusion is the priority action as it is essential to prevent further potential adverse effects and initiate an investigation of a possible transfusion reaction.
B. Assessing the skin for a rash is important but secondary to stopping the transfusion.
C. Notifying the provider is necessary, but the immediate priority is to stop the transfusion.
D. Covering the client with a blanket does not address the potential severity of a transfusion reaction.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Increased respiratory rate is a common finding in fluid overload due to pulmonary congestion and edema, which can affect breathing.
B. Increased temperature is not directly associated with fluid overload; it is more indicative of an infection or inflammatory process.
C. Increased heart rate can occur as the heart compensates for the increased blood volume and stress on the cardiovascular system.
D. Increased blood pressure is a typical response to fluid overload due to the higher volume of circulating blood.
E. Increased hematocrit is usually not associated with fluid overload; instead, it is often increased in conditions of dehydration or hemoconcentration.