When you speak with him alone in the room, he states it “would be better if he were not here.” What would you do next?
Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half.
A) Tell him that he has a very promising career in anything he chooses and soon he will feel better.
B) Tell him that he needs an antidepressant and it will take about 4 weeks to work.
C) Speak with his mother about getting him together more with his friends.
D) Assess his suicide risk.
D) Assess his suicide risk.
His lack of interest in usual activities and duration of symptoms should make you suspicious for depression. Despite his very successful academic and athletic performance, you should recognize this last phrase indicating suicide risk. You could ask if he has had thoughts about hurting himself and, if so, how he would carry this out. Ask about firearms and other weapons at home. Adam needs immediate psychiatric referral if these risks are found, or admission to the hospital for observation if referral is not available in a timely fashion.
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The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?
a. Notify the physician. b. Stop the irrigation temporarily. c. Increase the height of the irrigation. d. Medicate for pain and resume the irrigation.
The nurse is reviewing a client's blood work, noting the bicarbonate and carbon dioxide levels. Which of the following would the nurse expect to see clinically in the client? Standard Text: Select all that apply
1. With a low pH, and an increased level of carbon dioxide, the rate and depth of respirations will increase to compensate. 2. With a high pH, and a low carbon dioxide, the client might be hyperventilating. 3. With a high bicarbonate, the pH will be higher, and the rate and depth of respirations are reduced in order to retain carbon dioxide. 4. With a high bicarbonate, the pH will be lower, and the depth and rate of respirations will be unchanged. 5. With an increase in the rate and depth of respirations, the pH will increase.
The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?
a. The patient's lung sounds will remain clear. b. The patient will have urine output of at least 30 mL/hr. c. The patient will verbalize understanding of fluid restrictions. d. The patient's pitting pedal edema will resolve within 72 hours.
Which of the following should a nurse assess on an hourly basis in a client undergoing cardiac or vascular surgery?
A) Blood sugar level C) Mentation B) Fluid intake and urine output D) Blood pressure and pulse rate