On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

What drugs the client used for the suicide attempt.

When the client last took drugs for bipolar disorder.

Whether the client ever attempted suicide in the past.

Which family member has the client's suicide note.

Answer and Explanation

The Correct Answer is A

Choice A reason: Knowing the type and amount of drugs ingested is critical for immediate medical intervention and treatment.

Choice B reason: While important, the timing of the last dose for bipolar disorder is less urgent than the details of the suicide attempt.

Choice C reason: Past suicide attempts are relevant for a psychiatric evaluation but are not the immediate concern in an acute overdose situation.

Choice D reason: The location of the suicide note is less critical than the medical information needed to treat the client's overdose.

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Correct Answer is B

Explanation

Choice A reason: Massaging the back to promote diaphragmatic excursion can be beneficial but is not the most effective intervention compared to early mobilization.

Choice B reason: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.

Choice C reason: Noting areas of atelectasis on chest x-rays is important for monitoring, but it is not an intervention that actively prevents respiratory complications.

Choice D reason: Providing ice or oral liquids when the client passes flatus is related to gastrointestinal recovery, not respiratory complications.

A. Assess for discomfort when the procedure is completed. B. Instruct the client to keep hands under the sterile field. C. Pour cleansing solution onto the sterile cloth field. D. Verify that the client has given informed consent.

Correct Answer is D

Explanation

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

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On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications?

Correct Answer is B

Explanation

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Correct Answer is D

Explanation

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply.

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