A 15-year-old client was depressed due to the loss of the client's mother and was placed on venlafaxine (Effexor). Two weeks later the client returns to the clinic and says, "I am feeling worse and have no hope
" What nursing action is a priority? 1. Assess for suicidality.
2. Ask what the client enjoys.
3. Assess if the client is sleeping at night.
4. Evaluate how the client's other family members are coping.
1
Rationale: In the initial treatment period, children and adolescents may carry an increased risk of suicidal ideation and behavior. It would be a priority to assess the client's current risk. The other items may be part of the client's assessment but would not be a life or death priority at this time.
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Mr. Garcia has been taking antibiotics at home for the treatment of a respiratory infection for the past 6 days, and there is no evident improvement in his infection. Which of the following nursing assessments is most appropriate?
A) Assess Mr. Garcia's adherence to his medication regimen. B) Assess Mr. Garcia's home hygiene. C) Assess Mr. Garcia's understanding of his illness. D) Assess Mr. Garcia's use of herbal or alternative remedies.
The pregnant woman asks about sexual activity during her pregnancy. The nurse states that sexual activity should be:
a. avoided after the first trimester. b. ceased in the case of vaginal bleeding. c. continued throughout the pregnancy. d. limited to activity that does not include intercourse.
The nurse is caring for a client receiving continuous bladder irrigation following transurethral prostatectomy. When emptying the urine collection bag, the nurse notes that 500 mL of irrigant has infused with only 100 mL of drainage returned
Which is the priority action by the nurse? 1. Irrigating the outflow port using an irrigation syringe to determine patency 2. Notifying the health care provider immediately 3. Irrigating the irrigation port to determine patency 4. Continuing to monitor output
A nurse works in the intensive care unit. She enjoys being on the unit charge nurse team, the recruitment and retention team, and the peer evaluation team
The recruitment and retention team is responsible for hiring new employees into the intensive care unit. The five-member team, con-sisting of three registered nurses, a unit clerk, and a nurse's aide, conduct the interviewing process with key questions that were developed by the team. This is an example of ____. a. Centralized power b. Shared governance c. Span of control d. Vertical authority