The physician prescribed amitriptyline (Elavil) 50 mg tid for a severely depressed client 2 weeks ago. Which of the following nursing diagnoses would the nurse consider a priority?
1. Chronic low self-esteem
2. Risk for suicide
3. Noncompliance
4. Anxiety
ANS: 2
Clients with depression are at increased risk for suicide when they have been on antidepressant medication for 2 weeks, because they are regaining some energy but may not have achieved full therapeutic effect with mood improvement. 1. Self-esteem is important, but it is not the priority. 3. Evidence of noncompliance is lacking. 4. Data are not present to indicate that the client is ex-periencing anxiety.
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The nurse working in a gynecology office recognizes what sexual practice by a patient as a form of sexual expression that is illegal in the United States?
a. Public displays of affection b. Private sexual behavior c. Female circumcision d. Transgender surgery
Of the following skills, which is considered an invasive procedure? (Select all that apply.)
a. Administering oral medications b. Starting an intravenous (IV) line c. Repositioning the patient. d. Inserting a urinary catheter.
What is the most reliable method of patient identification for administration of medications?
a. A photograph of the patient b. An identification bracelet c. Asking the patient to repeat his or her name d. Use of the patient's room number
Answer the following statements true (T) or false (F)
1. An ostomy bag is sometimes called a stoma bag. 2. Wrinkled sheets may be one cause for a client's developing bedsores. 3. Soiled linens must be held away from the aide's body. 4. Supporting a weak client with pillows may help the client maintain a sitting position. 5. The nursing period for a breast-fed infant should be no longer than 15 minutes per feeding.