A nurse from a medical-surgical unit is assigned to an inpatient mental health unit. Which of the following clients should the charge nurse assign to the medical-surgical nurse?
A client who has depression and anxiety with an established plan of care
A client who is trying to engage in self-harm and does not understand why they cannot leave the facility
A client who is being discharged and needs information on substance abuse counseling
A client who has been placed in restraints and requires documentation every 15 min
The Correct Answer is A
A. A client who has depression and anxiety with an established plan of care: A medical-surgical nurse can safely care for a client with stable mental health conditions when a clear, established plan of care is in place. This client does not require constant psychiatric interventions, making it appropriate for assignment.
B. A client who is trying to engage in self-harm and does not understand why they cannot leave the facility: This client is high-risk and requires a nurse with specialized mental health training to implement safety measures and therapeutic interventions. Assigning this client to a medical-surgical nurse could compromise safety.
C. A client who is being discharged and needs information on substance abuse counseling: Discharge teaching and counseling for substance abuse require specialized knowledge and therapeutic communication skills typical of mental health nurses. A medical-surgical nurse may not have the expertise to provide adequate education and support.
D. A client who has been placed in restraints and requires documentation every 15 min: Clients in restraints require frequent monitoring, crisis intervention, and mental health expertise. This high-acuity situation is not appropriate for a nurse without psychiatric training.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Depression: Selegiline transdermal patches are indicated for the treatment of major depressive disorder. As a selective monoamine oxidase-B (MAO-B) inhibitor, it increases the availability of neurotransmitters such as dopamine, which can improve depressive symptoms in adults.
B. Anxiety: While selegiline may have indirect effects on mood, it is not primarily indicated for treating anxiety disorders. Anxiety may require other pharmacologic or therapeutic interventions specifically targeted to anxiety symptoms.
C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder often associated with long-term antipsychotic use. Selegiline does not treat or prevent tardive dyskinesia; it is not indicated for movement disorder management in this context.
D. Bipolar mania: Selegiline is not indicated for the management of bipolar disorder or acute manic episodes. Treating mania typically involves mood stabilizers or antipsychotics rather than MAO-B inhibitors.
Correct Answer is D
Explanation
A. Clean the insertion site with betadine: While povidone-iodine (Betadine) can be used, current guidelines recommend using chlorhexidine for central line site care because it is more effective in preventing catheter-related bloodstream infections. Using betadine is not the preferred standard of care.
B. Flush the catheter with sterile water: Central venous catheters should be flushed with sterile saline, not sterile water, to maintain patency and avoid hemolysis or electrolyte imbalance. Flushing with water can damage blood cells and the catheter.
C. Use a 5-mL syringe to flush the catheter: A minimum of a 10-mL syringe is recommended when flushing a central venous catheter because smaller syringes generate excessive pressure that can damage the catheter. Using a 5-mL syringe increases the risk of catheter rupture.
D. Wear sterile gloves when providing site care: Sterile technique is required when performing central line site care to prevent infection. Wearing sterile gloves protects the client from pathogens and is a critical step in maintaining asepsis during dressing changes and catheter maintenance.
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