A staff nurse tells another nurse "I just used the SAD PERSONS scale to evaluate a new client. His
score was 10 . I'm wondering if I should send him home after arranging for follow-up.". The best
reply by the second nurse would be
a. "That would seem appropriate.".
b. "Make sure he is followed up closely; he may require hospitalization in the near
future.".
c. "I think you should strongly consider hospitalization for him.".
d. "A score of 7 or higher usually requires immediate hospitalization.".
D
A SAD PERSONS scale score of 0 to 2 suggests home care with follow-up. A score of 3 to 4 calls
for close follow-up and possible hospitalization. A score of 5 to 6 requires the nurse to strongly
consider hospitalization, and a score of 7 or higher calls for hospitalization.
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A client is concerned about the risk of developing renal carcinoma. The nurse should respond by asking which of the following questions that would indicate the client may be at increased risk of developing of renal carcinoma?
1. "Do you smoke cigarettes?" 2. "Do you exercise regularly?" 3. "Are you taking any medications?" 4. "Do you take herbal supplements?"
A benzodiazepine has been prescribed for a client with short-term insomnia. Which benzodiazepine is appropriate to treat insomnia?
1. Diazepam (Valium) 2. Chlordiazepoxide (Librium) 3. Clonazepam (Klonopin) 4. Temazepam (Restoril)
When assessing the client's AV fistula, the nurse notes vibration at the fistula site. How should the nurse respond to this finding?
A. Contact the health care provider. B. Ask the client how long this has occurred. C. Determine when the fistula was placed. D. Document the finding.
The nurse develops a nursing diagnosis of "fluid volume excess related to sodium retention secondary to steroid therapy as evidenced by weight gain of 12 pounds in 2 weeks and edema of lower extremities." Which goal is most appropriate?
a. Patient will verbalize importance of low-sodium diet. b. Ankle circumference will be measured for edema daily. c. Patient's fluid volume will decrease as evidenced by discontinuing steroids. d. Patient will have improved fluid balance as evidenced by weight returning to baseline.