A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

"Can you tell me about the stresses in your life?"

"Has anyone in your family ever died by suicide?

“Do you have a plan for harming yourself?"

“Do you have someone to discuss your feelings with?"

Answer and Explanation

The Correct Answer is C

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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Correct Answer is C

Explanation

Explanation:

The Pavlik harness is a device used to treat developmental dysplasia of the hip (DDH) in infants. It helps position the hips in a way that promotes proper hip joint development. By keeping the hips in a flexed and abducted position, the harness helps to align the hip joint properly, allowing for normal development.

A- Applying lotion under the straps of the harness is not recommended as it can interfere with the harness's effectiveness and may cause skin irritation.

B- The harness should not be removed for sleeping unless specifically instructed by the healthcare provider. It is typically worn continuously to ensure consistent hip positioning and optimal treatment outcomes.

D- Placing the diaper over the strap of the harness is not recommended as it can cause discomfort for the infant and may interfere with the proper fit and function of the harness. The diaper should be placed under the harness straps to ensure a secure and comfortable fit.

A. Hyperglycemia B. Hypertension C. Hematuria, D. Tinnitus

Correct Answer is B

Explanation

Explanation

B.Hypertension

Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.

Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.

The other options are not specifically associated with the adverse effects of tranylcypromine:

Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.

Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.

Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.

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A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

Correct Answer is B

Explanation

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