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Question 1 of 5

During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?

Correct Answer: A

Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.

Question 2 of 5

Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications?

Correct Answer: D

Rationale: TPN can cause fluid imbalances due to high glucose and volume loads, requiring close monitoring of intake, output, and electrolytes.

Question 3 of 5

You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?

Correct Answer: C

Rationale: A multi-lumen implanted tunneled and cuffed central venous catheter is most appropriate for long-term IV therapy, blood products, and hyperalimentation due to its durability and reduced infection risk.

Question 4 of 5

A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:

Correct Answer: B

Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.

Question 5 of 5

The 2nd priority needs according to the MAAUAR method of priority setting include which of the following?

Correct Answer: D

Rationale: The MAAUAR method prioritizes: Mental status, Acute pain, Acute eliminated needs, Urgent needs, Abnormal vital signs, Risks. The second priority is Acute pain, but among the options, Risks aligns as a high-priority need following initial physiological concerns.

Similar Questions

A client with a history of schizophrenia is admitted with auditory hallucinations. The nurse should prioritize which of the following interventions?
A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client?
A client with a history of chronic kidney disease is admitted with hyperphosphatemia. The nurse should expect to administer which of the following medications?
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician orders include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 mL/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should:
A client with a chronic mental illness who does not always take her medications is separated from her husband and receives Supplemental Security Income. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and receives Social Security benefits. The client's sister works outside the home, and the client's father is dead. Which of the following issues should the nurse need to address first?

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