When the nurse performs the initial assessment of an adolescent with depression, what is the most important question to ask?
a. "What is making you depressed?"
b. "Have you ever thought about suicide?"
c. "What could we do to make you happy?"
d. "Would you like your friends to visit?"
ANS: B
Ask direct questions about suicidal thoughts. The discovery of whether the person has an actual plan is an indicator of the seriousness of the situation.
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A client's family member states, "I don't understand the reason for the methadone treatment. Why replace heroin with methadone?" What is the best explanation for this family?
1. Methadone is safe even in large doses. 2. Methadone replaces a more potent drug. 3. Methadone is a deterrent to the use of drugs. 4. Methadone blocks the craving for and the action of opiates.
A woman with a deep vein thrombosis (DVT) is receiving IV heparin therapy. Which nursing diagnosis does the nurse address as the priority?
A. Altered family processes B. Pain C. Risk for injury D. Self-care deficit
A nurse needs to administer an intramuscular injection to a client in the deltoid site. Which of the following actions will reduce the risk of damaging the client's radial nerve or artery?
A) Avoid asking the client to lie down or sit. B) Aspirate for blood return from the tissue. C) Draw an imaginary line at the axilla between the acromion and brachial vessels. D) Pull the tissue laterally until it is taut.
The nurse in the health center on a college campus is talking to freshman students about the consequences of drinking alcohol. The nurse defines a standard drink as:
A) 12 ounces of regular beer. B) 6 ounces of malt liquor. C) 4 ounces of table wine. D) 3 ounce shot of whiskey.