A client comes to the emergency department complaining of a severe pounding headache in the temples and a stiff neck. The client is flushed and diaphoretic, and his pulse is racing. The client states that he is being treated for depression with selegiline. Which question by the nurse would be most important to ask at this time?

Correct Answer: B

Rationale: The correct answer is B: "What have you had to eat or drink today?" This question is important because the client is taking selegiline, a monoamine oxidase inhibitor (MAOI), which has dietary restrictions. Foods high in tyramine can lead to a hypertensive crisis when combined with MAOIs. The client's symptoms of severe headache, flushing, and diaphoresis are indicative of a potential hypertensive crisis. By asking about the client's recent dietary intake, the nurse can assess for potential tyramine-containing foods that may have triggered the symptoms. Choice A: "When did you last have blood drawn to check your drug level?" is not as important at this time because the client's symptoms suggest an acute issue that requires immediate intervention, rather than monitoring drug levels. Choice C: "Are you having any chest pain?" is important for assessing cardiac involvement but is not the most crucial question in this scenario. Choice D: "Do you use any herbal remedies

Correct Answer: D

Rationale: The correct answer is D: "Would you like to play a game of checkers with me?" This choice is most appropriate as it focuses on building a therapeutic relationship through a non-threatening and engaging activity. Playing a game of checkers can help establish rapport, foster trust, and create a sense of normalcy for the child in a psychiatric setting. It allows for social interaction, provides a distraction, and can help the child feel more comfortable and open up to the nurse. Explanation of why the other choices are incorrect: A: Comparing the child's situation to Cinderella's in a fairy tale may not be relatable or relevant to the child's experiences, potentially minimizing their feelings and concerns. B: Using a tool to measure self-control and initiative may come off as clinical and impersonal, possibly making the child feel like they are being evaluated rather than supported. C: Asking the child to draw a picture of themselves may be intimidating or invasive, as it delves into personal expression without

Correct Answer: C

Rationale: The correct answer is C: Imbalanced nutrition. This is the priority because it addresses the client's physiological needs, which are essential for survival and overall well-being. The nurse should prioritize addressing basic needs such as nutrition before addressing psychological or social needs. Anxiety (A), powerlessness (B), and impaired social interaction (D) are important but secondary to addressing the client's immediate physiological needs. It is important to address the most critical issue first to ensure the client's health and safety.

Correct Answer: C

Rationale: The correct answer is C because it shows a mentally healthy perspective of taking responsibility and being proactive in making positive changes for the benefit of the family. By acknowledging the need for personal growth and willingness to change behavior, this family member demonstrates self-awareness and a commitment to improving relationships. Choice A is incorrect as it deflects responsibility by comparing oneself to others. Choice B reminisces about the past without addressing current issues or solutions. Choice D is not a healthy approach as it suggests avoidance rather than addressing and working through familial conflicts.

Correct Answer: A

Rationale: The correct answer is A: Initiate droplet precautions for the client. This is appropriate because bacterial meningitis is transmitted through droplets, so implementing droplet precautions helps prevent the spread of infection to others. Option B (Assist the client to a supine position) is incorrect as it can worsen intracranial pressure. Option C (Perform the Glasgow coma scale every 24 hours) is not directly related to preventing transmission of infection. Option D (Recommend prophylactic acyclovir for the client's family) is incorrect as acyclovir is used for herpes simplex virus, not bacterial meningitis.