The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Initiate droplet precautions

Initiate airborne precautions

Place the client in a positive pressure room

Initiate neutropenic precautions

Answer and Explanation

The Correct Answer is B

B. Airborne precautions are used for diseases that can be transmitted through tiny respiratory droplets that remain in the air for extended periods. Examples include tuberculosis and measles. Given the symptom of coughing up blood and the possibility of an infectious respiratory disease, initiating airborne precautions could be warranted.
A. Droplet precautions are typically implemented for diseases that spread through respiratory droplets, such as influenza or pertussis. However, coughing up blood suggests a more serious condition that may not be adequately addressed by droplet precautions alone.
C. Positive pressure rooms are typically used in healthcare settings to prevent outside air from entering the room, thus reducing the risk of airborne contaminants. While this measure can be beneficial for certain conditions, such as those requiring airborne precautions, it may not be the priority intervention.
D. Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). While this precaution is important for protecting immunocompromised patients from infections, it may not be the priority intervention.

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Correct Answer is C

Explanation

C. This attitude suggests a sense of self-blame or low self-worth commonly seen in individuals with depression. They may feel undeserving of happiness or believe that their suffering is justified. This attitude can hinder the individual's willingness to seek help or engage in treatment, as they may believe that they do not deserve support or that their situation is hopeless.
A. This attitude may reflect optimism or hopefulness which is not a common finding in individuals with depression. Hopelessness is more common in depression.
B. This attitude reflects a sense of determination and agency in overcoming the illness. This is not a typical finding in depression.
D. Some individuals with depression may attempt to cope by minimizing or ignoring their symptoms, hoping that they will resolve on their own. However, untreated depression typically does not improve without intervention and may worsen over time.

A. denial. B. separation-individuation. C. splitting. D. reaction formation.

Correct Answer is C

Explanation

C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.

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The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During assessment, the nurse is most likely to find the attitude of the depressed client toward his illness to be:

Correct Answer is C

Explanation

The nurse has recently set limits for a client with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful." This outburst can be assessed as:

Correct Answer is C

Explanation

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