A charge nurse on a mental health unit is receiving change of shift report for a group of clients. The charge nurse is working with an RN, an LPN, and assistive personnel (AP) from 0700 to 1900 and is reviewing client care assignments. Complete the following sentence by using the lists of options.

The charge nurse should first assess the client who has a 7-year history of major depressive disorder, whose friend reports the client has stopped taking their medication, and who is flat, withdrawn, cries all the time, sleeps all the time, and has extremely slowed movements, due to the risk of Select.

suicide

dehydration

infection

seizure

Answer and Explanation

The Correct Answer is A

Choice A reason: The risk of suicide is the highest priority for the charge nurse to assess. The client has several risk factors for suicide, such as major depressive disorder, medication noncompliance, hopelessness, social isolation, and psychomotor retardation. The charge nurse should evaluate the client's suicidal ideation, intent, and plan, and implement safety measures as needed.

Choice B reason: The risk of dehydration is a lower priority than the risk of suicide. The client may be dehydrated due to decreased fluid intake, but this is not a life-threatening condition. The charge nurse should monitor the client's hydration status and encourage oral fluids as appropriate.

Choice C reason: The risk of infection is a lower priority than the risk of suicide. The client does not have any signs or symptoms of infection, such as fever, chills, or leukocytosis. The charge nurse should assess the client's vital signs and laboratory results as indicated, but this is not an urgent issue.

Choice D reason: The risk of seizure is a lower priority than the risk of suicide. The client does not have any history or risk factors for seizure, such as epilepsy, head trauma, or drug withdrawal. The charge nurse should observe the client for any abnormal movements or behaviors, but this is not a likely complication.

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Correct Answer is C

Explanation

Choice A reason: Report of photophobia is a common finding in clients who have meningitis, as the inflammation of the meninges causes sensitivity to light. However, this is not an urgent finding that requires immediate reporting to the provider.

Choice B reason: Increased temperature is a common finding in clients who have meningitis, as the infection causes fever and systemic inflammation. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is very high or accompanied by other signs of sepsis.

Choice C reason: Decreased level of consciousness is an urgent finding in clients who have meningitis, as it indicates increased intracranial pressure, cerebral edema, or brain herniation. These are life-threatening complications that require immediate intervention and treatment.

Choice D reason: Generalized rash over trunk is a common finding in clients who have meningococcal meningitis, as the bacteria cause petechiae and purpura on the skin. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is extensive or associated with bleeding or shock.

A. Provide the UAP with the infection control policy. B. Offer to assist the UAP with the collection of the specimen. C. Determine the UAP's knowledge about HIV transmission. D. Demonstrate the proper use of personal protective equipment.

Correct Answer is C

Explanation

The correct answer is c.

Choice A reason: Providing the UAP with the infection control policy is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.

Choice B reason: Offering to assist the UAP with the collection of the specimen is not the first action the charge nurse should take. The charge nurse should first address the UAP's fear and educate the UAP about HIV transmission and infection control measures.

Choice C reason: Determining the UAP's knowledge about HIV transmission is the first action the charge nurse should take. This will help the charge nurse identify any knowledge gaps or misconceptions the UAP may have and provide appropriate education and reassurance.

Choice D reason: Demonstrating the proper use of personal protective equipment is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is C

Explanation

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

Correct Answer is C

Explanation

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