A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Urinary retention

Blurred vision

Headache

Bradypnea

Answer and Explanation

The Correct Answer is D

Choice A reason:

Urinary retention can be a side effect of both diazepam and hydromorphone, but it is not typically life-threatening. While it should be monitored and addressed, it is not the most urgent concern compared to respiratory issues.

Choice B reason:

Blurred vision can occur with the use of diazepam and hydromorphone, but it is generally not an immediate threat to the client’s life. It should be reported and managed, but it is not the highest priority.

Choice C reason:

Headache is a common side effect of many medications, including diazepam and hydromorphone. While it can be uncomfortable and may need treatment, it is not usually a sign of a life-threatening condition.

Choice D reason:

Bradypnea, or slow breathing, is a serious side effect that can occur with the use of both diazepam and hydromorphone, as both medications depress the central nervous system. This can lead to respiratory depression, which is potentially life-threatening and requires immediate medical attention.

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Correct Answer is B

Explanation

Choice A reason:

ECT is not contraindicated in clients with psychotic symptoms. In fact, it is often used to treat severe depression with psychotic features, as well as other conditions such as mania and catatonia. ECT can be highly effective in reducing symptoms of psychosis when other treatments have failed.

Choice B reason:

ECT is delivered through electrodes attached to the head. During the procedure, a small amount of electrical current is passed through the brain to induce a controlled seizure, which can help alleviate symptoms of severe depression and other mental health conditions.

Choice C reason:

ECT can be administered to clients with suicidal ideation. It is often considered when rapid symptom relief is needed, such as in cases of severe depression with a high risk of suicide. ECT can provide quick and significant improvement in mood and functioning.

Choice D reason:

ECT is conducted under general anesthesia, not regional anesthesia. General anesthesia ensures that the client is unconscious and does not feel pain during the procedure. Muscle relaxants are also administered to prevent physical convulsions during the induced seizure.

A. “I agree with you. I’m sure this will never happen again.” B. “This is awful. You should file charges against your partner.” C. “This is clearly child endangerment. I will have to call the police.” D. “I’d like to know more about what happened. Let’s sit and talk.”

Correct Answer is D

Explanation

Choice A reason:

Agreeing with the parent and assuming the situation will not happen again is not appropriate. It dismisses the potential risk to the child and does not address the seriousness of the situation.

Choice B reason:

Telling the parent to file charges against their partner is a strong directive that may not be appropriate without further understanding of the situation. It is important to gather more information before making such recommendations.

Choice C reason:

Stating that the situation is clearly child endangerment and immediately calling the police may escalate the situation without fully understanding the context. It is important to assess the situation thoroughly before taking such actions.

Choice D reason:

Expressing a desire to know more about what happened and offering to talk is an appropriate response. It allows the nurse to gather more information, assess the situation, and provide support to the parent and child.

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A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child’s parent states, “My partner got fired today and came home angry. I don’t think this will happen again.” Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?

A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?

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A charge nurse is providing education to a group of newly licensed nurses about the rights of clients who are involuntarily admitted. Which of the following responses indicates understanding of the teaching?

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A nurse is caring for a client who exhibits excessive attention-seeking behaviors, including acting flirtatious and seductive. The nurse should identify these behaviors as manifestations of which of the following personality disorders?

A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?