A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?

Correct Answer: C

Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety. 1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation. 2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention. 3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts. Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.

Correct Answer: D

Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.

Correct Answer: A

Rationale: The correct answer is A: Decreased urine specific gravity. In diabetes insipidus, there is an inability to concentrate urine, leading to decreased urine specific gravity. This is due to the decreased production or action of antidiuretic hormone (ADH). As a result, the kidneys are unable to reabsorb water efficiently, causing dilute urine with low specific gravity. Incorrect choices: B: Elevated urine glucose is more indicative of diabetes mellitus, not diabetes insipidus. C: Decreased serum potassium is not a typical finding in diabetes insipidus. D: Increased serum sodium can occur due to dehydration from excessive urination in diabetes insipidus, but it is not directly indicative of the condition.

Correct Answer: D

Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery. Rationale for other choices: A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation. B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention. C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.

Correct Answer: B

Rationale: The correct answer is B: Increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate hypotension, tachycardia, decreased urine output, and cool skin, suggesting hypovolemic shock. Increasing IV fluid rate will help to restore intravascular volume and improve perfusion to vital organs. This is the highest priority as it addresses the immediate physiological need for circulatory support. Choice A is incorrect because hypothermia is not indicated based on the client's presentation. Choice C is incorrect as it does not address the client's urgent physiological needs. Choice D is incorrect as drawing blood cultures, while important, is not the most immediate priority in this situation.