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Questions 164

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Question 1 of 5

The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.

Correct Answer: A,C,D,F

Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.

Question 2 of 5

A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?

Correct Answer: D

Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.

Question 3 of 5

The nurse is caring for a client with a history of headaches who has come to the clinic reporting a 'bad migraine.' The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?

Correct Answer: B

Rationale: Flat affect and drowsiness in a migraine are atypical and may indicate a more serious condition like a neurological event, requiring urgent evaluation. Nausea and poor appetite are common in migraines, and the BP and respiratory rate are within normal limits.

Question 4 of 5

The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.

Correct Answer: A,D

Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).

Question 5 of 5

Which situations would prompt the health care team to use the client’s advance directive to make a decision regarding care? Select all that apply.

Correct Answer: B,D

Rationale: Advance directives guide care when clients cannot communicate decisions, as with a GCS of 3 (unconscious) or aphasia from hemorrhage. Paraplegia, religious refusal, and ventilator use in an oriented client do not impair decision-making capacity.

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