During his first interview at the crisis center, a client who is having suicidal ideation associated with
divorce proceedings tells the nurse he has usually been able to talk over problems with his sister.
He
also states he finds playing the bagpipes relaxing but had given them up when be became an
apartment dweller. He mentions that he took diazepam (Valium) for a short time several years ago
but did not like the side effects. The nurse should help the client weigh the consequences of various
alternatives, including (more than one answer may be correct)
A. visiting his sister to talk about his problem.
B. joining a pipe band at the local YMCA.
C. returning to the clinic in 24 hours.
D. taking diazepam four times daily.
A, B, C
Rationale: Options A and B use previously effective coping strategies that could be helpful in this
instance. Option C is advisable because it provides ongoing support and promotes the feeling that
the client is not alone. Option D would not be useful because the client disliked the medication's side
effects. Furthermore, anxiolytics may not be necessary if other options are successful.
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While preparing a pain medication for a client, the nurse notes that there is a discrepancy with the last removal and reports the incident. Which is an expected consequence of the nurse's action?
A) Being sued by the nurse who made the error B) Being ostracized by the staff C) Being protected by the law D) Being summoned to testify
A client with blood type B negative has given birth to an infant with blood type O positive. When should the client receive Rh immune globulin?
a. only if she plans any future pregnancies b. only if she has had an Rh-negative infant c. right after the delivery of her infant d. within 72 hours after delivery
A patient is prescribed bupropion (Wellbutrin SR) 100 mg twice daily. It is time for the second dose today and the drug sent up from the pharmacy is Wellbutrin 100 XL. What is the nurse's best action?
a. Administer the Wellbutrin XL tablet in place of the Wellbutrin SR tablet. b. Cut the Wellbutrin XL tablet in half and then administer it. c. Call the pharmacy and obtain a Wellbutrin SR 100 mg tablet. d. Hold the dose and notify the prescriber.
The nurse is caring for a client who has bursitis related to gout. What is an appropriate nursing intervention for this client?
A) Applying heat to the affected part B) Applying cold compresses to the affected part C) Providing AROM for the affected part D) Administering antibiotics as prescribed