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Question 1 of 5

Which of the following statements relevant to a suicidal client is correct?

Correct Answer: A

Rationale: This is a high-risk factor for potential suicide. A previous suicide attempt is a definite risk factor for subsequent attempts. Every threat of suicide should be taken seriously. The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.

Question 2 of 5

A client with a history of a heart failure is receiving Digoxin (Lanoxin). The nurse should monitor the client for:

Correct Answer: B

Rationale: Digoxin toxicity can cause visual disturbances (e.g., yellow-green halos), requiring monitoring. Tachycardia, hypotension, and weight loss are less specific.

Question 3 of 5

The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1-2 minutes; strong, large amount of 'bloody show.' The most appropriate nursing goal for this client would be:

Correct Answer: C

Rationale: In transition (9 cm dilation, frequent contractions), helping the client maintain control is critical due to intense contractions and emotional challenges.

Question 4 of 5

A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

Correct Answer: B

Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.

Question 5 of 5

Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

Correct Answer: A

Rationale: A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases.
Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated.

Similar Questions

A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim-sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104°F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells Rankings blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

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