A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

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Question 1 of 5

A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

Correct Answer: A

Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications. Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.

Question 2 of 5

A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?

Correct Answer: B

Rationale: The correct answer is B because verbalizing feelings and concerns can help the patient process and understand their emotions, making them feel less overwhelming. This can facilitate problem-solving by breaking down complex issues into smaller, manageable parts. By talking about their concerns, the patient can also receive support and feedback from the nurse, leading to a sense of relief and empowerment. Incorrect answer explanations: A: Offering hope may be comforting but does not directly address the patient's current anxiety by helping them process and verbalize their feelings. C: Focusing on the environment may not necessarily address the patient's internal feelings and concerns, which are key in managing anxiety. D: While exploring alternatives can increase a sense of control, it may not directly address the immediate need to process and verbalize emotions to reduce anxiety.

Question 3 of 5

A nurse is performing an assessment interview of a 14-year-old boy who is being admitted to an adolescent substance abuse unit. His parents are concerned about their son's repeated problems at school that they associate with his drug use. The boy stalks into the office, abruptly sits down, crosses his arms, and says, 'Okay, ask your stupid questions, but don't expect me to cooperate!' Which response by the nurse would be most appropriate?

Correct Answer: D

Rationale: The correct response is D because it acknowledges the boy's emotions, shows empathy, and invites him to share his feelings. By acknowledging his upset feelings, the nurse can build rapport and establish trust, which is crucial in therapeutic communication. This response also opens the door for the boy to express himself and potentially reveal the underlying reasons for his behavior. Choices A and C are confrontational and judgmental, which can escalate the situation and hinder communication. Choice B suggests waiting until the boy calms down, which may be dismissive of his emotions and doesn't address the immediate need for connection and understanding.

Question 4 of 5

After describing the various legislative efforts to address the issue of homelessness in the United States, a nursing instructor determines that the teaching was successful when the students identify which of the following as addressing the need for a continuum of care approach?

Correct Answer: D

Rationale: The correct answer is D: McKinney-Vento Homeless Assistance Act. This act addresses the need for a continuum of care approach by providing federal funding for homeless assistance programs that offer a range of services to individuals experiencing homelessness. It emphasizes the importance of coordination among various service providers to ensure a seamless transition from emergency shelters to permanent housing. Choice A: Bringing Home America Act does not specifically focus on homeless assistance programs or the continuum of care approach. Choice B: Affordable Care Act primarily focuses on healthcare reform and expanding access to healthcare services, not specifically related to addressing homelessness. Choice C: American Recovery and Reinvestment Act aims to stimulate economic recovery through job creation and infrastructure projects, not directly related to addressing homelessness or providing a continuum of care approach.

Question 5 of 5

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?

Correct Answer: D

Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates suicidal ideation and intent. Priority is to ensure immediate safety. Suicide precautions involve continuous monitoring, removing harmful objects, and providing a safe environment. A: Self-esteem activities, B: Anxiety measures, and C: Sleep enhancement are important, but not the priority when a patient is at risk of self-harm.

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