A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

Initiates an exercise program to help deal with stress.

Identifies four positive personal traits.

Returns to previous level of functioning.

Describes what is needed in a romantic relationship.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Initiating an exercise program may be a helpful intervention, but the primary goal for this client following a drug overdose and romantic relationship issues is to return to the previous level of functioning.

Choice B rationale: Identifying positive personal traits is a positive goal but may not be the most immediate priority for this client.

Choice C rationale: Returning to the previous level of functioning is the primary goal for hospitalization. This goal involves restoring the client's ability to manage daily life and cope with stressors.

Choice D rationale: Describing what is needed in a romantic relationship is important, but the immediate focus is on the client's overall functioning and safety.

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Correct Answer is C

Explanation

Choice A rationale: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.

Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.

Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.

Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.

A. Encourage Increase Intake of oral fluids. B. Obtain a specimen for a complete blood count. C. Complete an Abnormal Involuntary Movement Scale (AIMS). D. Administer a PRN dose of acetaminophen.

Correct Answer is B

Explanation

Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.

Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).

Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.

Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.

Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.

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A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is C

Explanation

A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

Correct Answer is B

Explanation

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

A young woman is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to Include in this phase of the nurse-client relationship?

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Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

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A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?