A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Disturbed body image related to depression

Imbalanced nutrition: Less than body requirements related to depression

Hygiene self-care deficit related to depression

Risk for self-directed violence related to depression

Answer and Explanation

The Correct Answer is D

A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.

B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.

C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.

D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.

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Correct Answer is B

Explanation

A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.

B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.

C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.

D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.

A. blurred vision B. urinary retention C. diarrhea D. headache E. pale, moist skin

Correct Answer is ["A","B"]

Explanation

A. blurred vision: Blurred vision is a common side effect of tricyclic antidepressants due to their anticholinergic effects, and it can be a sign of overdose.

B. urinary retention: Urinary retention is another anticholinergic side effect of tricyclic antidepressants and can indicate an overdose.

C. diarrhea: Diarrhea is not typically associated with tricyclic antidepressant overdose. Anticholinergic effects generally lead to constipation, not diarrhea.

D. headache: While a headache can occur in many situations, it is not a specific indicator of tricyclic antidepressant overdose.

E. pale, moist skin: Pale, moist skin is not a typical symptom of tricyclic antidepressant overdose. Overdose symptoms more commonly include dry skin due to anticholinergic effects.

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A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Correct Answer is B

Explanation

A client who is prescribed a tricyclic antidepressant is brought to the emergency department with a suspected overdose. Which would the nurse assess to support this suspicion? Select all that apply.

Correct Answer is ["A","B"]

Explanation

The nurse is providing education via phone to a client who called stating that the newly prescribed imipramine (Tofranil) is not working as depression is still a problem. Which question is most important to ask first?

A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?

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Carbamazepine has a boxed warning for which adverse effect?

A client's most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

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A nurse is preparing to administer prednisone to a client for treatment of rheumatoid arthritis. Which of the following findings indicates to the nurse the treatment is effective?