A nurse suspects that a client is depressed. Which of the following symptoms is most likely being exhibited by the client? (Select all that apply.)
a. Paranoia
b. Fatigue
c. Irritability
d. Difficulty concentrating
e. Hallucinations
f.
Impulsivity
ANS: B, C, D
Symptoms of depression include the following: persistent sad, anxious, or "empty" feelings; feelings of hopelessness or pessimism; feelings of guilt, worthlessness, or helplessness; irritability, restlessness; loss of interest in activities or hobbies once pleasurable, including sex; fatigue and decreased energy; difficulty concentrating, remembering details, and making decisions; insomnia, early-morning wakefulness, or excessive sleeping; overeating or appetite loss; thoughts of suicide, suicide attempts; aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.
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A mother reports that she and her husband have had one child together, but both have children from previous marriages living in their home. The nurse will base the care planning on what type of family?
a. Nuclear b. Blended c. Alternate d. Extended
Which serious reaction should the nurse be alert for when administering vaccines?
a. Fever b. Skin irritation c. Allergic reaction d. Pain at injection site
The client has MRSA and receives vancomycin (Vancocin) intravenously (IV). The nurse assesses an upper body rash and decreased urine output. What is the nurse's priority action?
1. Hold the next dose of vancomycin (Vancocin), and notify the physician. 2. Obtain a stat X-ray, and notify the physician. 3. Administer an antihistamine, and notify the physician. 4. Obtain a sterile urine specimen, and notify the physician.
An apical pulse is checked
A. for one full minute. B. after the nurse gives a heart medication. C. on children 12 or younger. D. on patients over age 65.