The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted disease (STD). The nurse realizes that such risk-taking behavior is often a predictor of even more serious self-destructive behaviors, and so this client should be:
1. Screened for illegal drug use
2. Assessed for suicidal ideations
3. Interviewed regarding alcohol consumption
4. Provided information regarding birth control
ANS: 2
Low self-esteem and stressful life events significantly predict suicidal ideations in adolescents. Nurses in all health care settings need to initiate suicide screening and implement nursing inter-ventions directed toward suicide prevention and early detection. Although the remaining options are areas that should be addressed, suicidal ideations are the most serious possible risk-taking behavior.
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Family members of a dying patient are arguing about terminating life support. The nurse educates the two opposing groups individually about terminating life support and discusses the dying process. This is an example of:
a. delegation. b. negotiation. c. clinical judgment. d. purposeful inaction.
6) The nurse cares for clients with a variety of depression disorders. Which client statements suggest the diagnosis of dysthymia? Select all that apply.
A) "Every day for over 2 years I've been sad, tired, and can't seem to get my act together." B) "Ever since my husband died 2 weeks ago, I can't concentrate and have no reason to live." C) "I've been feeling down in the dumps for about 2 weeks now." D) "For the last 4 years, I can't make a decision and am so worthless at work every day." E) "For the last year, I have periods of time that I am sad and cry a lot."
A client diagnosed with bipolar disorder is prescribed lithium carbonate. Which of the following should the nurse confirm to ensure that lithium carbonate is not contraindicated in the client?
A) Client is not pregnant or lactating. B) Client is not perimenopausal. C) Client does not have high blood pressure. D) Client is not experiencing menopause.
The patient has a potassium level of 5.9 mEq/L. The nurse is administering glucose and insulin. The patient's wife says, "He doesn't have diabetes, why is he getting insulin?" What is the best response by the nurse?
1. "Insulin will cause his extra potassium to go into his cells and lower the blood level." 2. "Insulin lowers his blood sugar levels and this is how the extra potassium is excreted." 3. "Insulin is safer than giving laxatives such as Kayexalate." 4. "Insulin will help his kidneys excrete the extra potassium."