A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)
Traumatic brain injury
Chronic pain
Sexual Dysfunction
Depression
Effective coping strategies
Risk for suicide
Correct Answer : A,D,F
A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.
B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.
C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.
D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.
E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.
F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While monitoring sodium levels can be important for clients on certain
medications, it is not a primary concern with lamotrigine. The main concern is the potential for a serious rash.
B) Correct. Lamotrigine is associated with a risk of a severe skin reaction called Stevens Johnson syndrome. If a client experiences any rash while taking lamotrigine, it is crucial to notify a
healthcare provider immediately.
C) Incorrect. While monitoring weight and potential changes in appetite are important aspects of overall health, it is not a specific teaching point for lamotrigine.
D) Incorrect. While it is important for individuals of childbearing age to discuss pregnancy plans and contraceptive methods with their healthcare provider, it is not the primary teaching point specific to lamotrigine.
Correct Answer is B
Explanation
A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.
B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.
C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.
D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.
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