An emergency code was called after a patient pulled a knife from a pocket and threatened, 'I will kill anyone who tries to get near me.' The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient

Correct Answer: D

Rationale: The correct answer is D because the patient's action of pulling out a knife and making a threat demonstrated a clear and present danger to others. The patient's behavior posed an immediate risk to the safety of those around them, necessitating urgent intervention for the protection of others. A: While the patient was indeed threatening to others, the severity of the threat, involving a weapon, indicated a higher level of danger. B: Psychosis alone may not always indicate an immediate danger to others unless accompanied by specific threatening behavior. C: While escape risk is a consideration, the primary concern in this scenario was the patient's potential harm to others, justifying seclusion for safety reasons.

Correct Answer: C

Rationale: The correct answer is C. Administer prescribed medication morphine for pain control. In this scenario with a 'DNR-CCO' order, the focus is on comfort care rather than resuscitation. Administering morphine for pain control aligns with the patient's wishes and provides comfort during a potentially distressing event. Calling for the code team (A) and initiating CPR (D) would go against the DNR order. Notifying the attending physician and family (B) is important but not the immediate nursing action needed during a cardiac arrest in this case.

Correct Answer: B

Rationale: The correct answer is B: "We'll need to make sure that he has his blood count checked at least weekly." Rationale: 1. Clozapine can cause agranulocytosis, a potentially life-threatening condition characterized by a severe decrease in white blood cells. 2. Monitoring blood counts weekly is crucial to detect early signs of agranulocytosis and intervene promptly. 3. Regular blood count monitoring allows for timely adjustments in medication dosage to prevent serious complications. Summary: A: Although monitoring the client's heart is important, regular electrocardiograms are not specifically required for clozapine. C: Smoking does affect clozapine levels, but this choice does not address the crucial need for blood count monitoring. D: Weight loss is a potential side effect of clozapine, but it is not the most critical monitoring parameter for this medication.

Correct Answer: A

Rationale: The correct answer is A: Danger Assessment Screen. This tool is specifically designed to assess the risk of lethality in individuals who have experienced abuse. It includes questions related to the severity and frequency of abuse, as well as other risk factors such as access to weapons and history of threats. It helps identify clients at high risk of harm or death. B: Abuse Assessment Screen is a screening tool to identify abuse but does not specifically focus on lethality risk. C: Burgess-Partner Abuse Scale is a measure of the frequency and severity of intimate partner violence, but it does not assess lethality risk. D: Beck Depression Inventory is a tool to assess the severity of depression and is not designed to evaluate the risk of harm or death in abuse survivors.

Correct Answer: B

Rationale: The correct answer is B because it highlights the importance of checking for congruence between verbal and nonverbal communication to validate responses. This demonstrates an understanding that nonverbal cues can provide additional insights into a patient's true feelings or thoughts. Choice A is incorrect as it simply states a general observation without emphasizing the significance of nonverbal cues. Choice C is incorrect because assuming a patient's emotions based solely on body posture is not accurate or reliable. Choice D is incorrect as it undervalues the importance of nonverbal communication in understanding the complete message being conveyed.