Question

A nurse on a mental health unit is assisting with the admission of a client.

Answer 1

Correct Answers

Blank 1 Correct Option: self-harm
Blank 2 Correct Option: command hallucinations

Rationale :

🔷 The client reports voices saying they are “worthless” and that they need to be “gone forever,” which signals suicidal content.

🔷 Hearing voices that are directing the client to act is a classic sign of command hallucinations, which significantly increases risk for self-harm.

🔷 The statement that “they are going to help me plan a way to do it” indicates intent and planning, making this an immediate safety priority.

🔷 In schizophrenia, auditory hallucinations with self-harm commands require rapid interventions such as safety precautions, close observation, and provider notification.

🔷 Because the client also refused aripiprazole, symptom control is reduced, further elevating the risk for impulsive self-injury.

Hyponatremia

🔷Excessive water intake can contribute to hyponatremia, but the client’s most urgent cue is the presence of self-harm commands.

🔷Safety threats from suicidal command hallucinations take priority over potential electrolyte imbalance.

Neuroleptic malignant syndrome

🔷NMS is associated with antipsychotic use and presents with fever, rigidity, autonomic instability, and altered mental status, which are not described here.

🔷The client actually refused the antipsychotic, making NMS less supported by the current findings.

Water intake

🔷Excess water intake is concerning and can lead to electrolyte disturbances, but it does not indicate the highest immediate risk compared with direct self-harm content.

🔷The most dangerous evidence is the client’s verbalized command hallucinations to die.

Prescribed aripiprazole

🔷A prescribed antipsychotic itself does not prove the client’s highest risk; risk is shown by current clinical cues.

🔷The stronger evidence is the client describing voices directing suicide-related actions.

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Answer 2

Correct Answers:

Provide staff with alcohol-based antibacterial hand gel.

Rationale :

🔷 Escherichia coli (E. coli) spreads primarily through the fecal–oral route, often from contaminated hands, food, or surfaces.

🔷 The most effective control measure in long-term care is strict hand hygiene, especially before food handling and after toileting or brief changes.

🔷 Providing alcohol-based hand gel increases access and compliance with hand hygiene, which reduces organism transmission between residents and staff.

🔷 Hand hygiene is a core infection prevention strategy that interrupts contact spread in communal living settings.

🔷 The nurse should also reinforce hand hygiene technique and ensure gloves are used appropriately when exposure to stool is possible.

Instruct staff to use airborne precautions.

🔷E. coli is not transmitted through airborne particles.

🔷It is typically spread by contact with contaminated stool or surfaces.

Administer prophylactic antiviral medication to the residents.

🔷E. coli is a bacterium, not a virus, so antivirals are ineffective.

🔷Prophylactic medication is not a standard prevention approach for controlling E. coli spread in facilities.

Direct staff to rinse their hands for 10 seconds after washing with soap.

🔷Effective handwashing requires at least 20 seconds of friction with soap and water.

🔷Ten seconds is too short to reliably remove organisms.

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Answer 3

Correct Answers

Blank 1 Correct Option: Reye syndrome
Blank 2 Correct Option: aspirin administration

Rationale :

🔷 The toddler had confirmed Influenza A, and the parents report giving aspirin, which is strongly associated with Reye syndrome in children with viral illness.

🔷 Reye syndrome causes acute hepatic dysfunction and cerebral edema, which can present as vomiting, lethargy, and decreased level of consciousness.

🔷 The child is now difficult to arouse and frequently vomiting, which are red flags for neurologic compromise rather than uncomplicated flu.

🔷 The report of no void today plus dry mucous membranes suggests worsening systemic illness and possible dehydration, increasing urgency for evaluation.

🔷 This situation requires immediate escalation because Reye syndrome can rapidly progress to seizures, coma, and life-threatening intracranial pressure.

Bronchitis

🔷Bronchitis usually presents with worsening productive cough, wheezing, or respiratory distress, not profound lethargy and repeated vomiting.

🔷The toddler’s respirations are easy and unlabored with clear lungs, making bronchitis less supported.

Gastroenteritis

🔷Gastroenteritis can cause vomiting and dehydration, but it does not typically cause a child to become difficult to arouse following aspirin use with influenza.

🔷The clinical picture is more consistent with a serious complication linked to aspirin + viral infection.

oseltamivir administration

🔷Oseltamivir may cause mild GI upset, but it does not explain progressive lethargy and significant neurologic changes.

🔷The highest-risk trigger here is aspirin exposure during a viral illness.

acetaminophen administration

🔷Acetaminophen is the recommended antipyretic for children and is not linked to Reye syndrome.

🔷Toxicity would require excessive dosing and typically presents with liver injury signs rather than this classic aspirin-viral pattern.

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Answer 4

Correct Answers:

Pull the pin out of the extinguisher.

Rationale :

🔷 After activating the alarm, the nurse should use the PASS method: Pull, Aim, Squeeze, Sweep.

🔷 Pulling the pin breaks the tamper seal and unlocks the handle so the extinguisher can discharge.

🔷 This is the first operational step required before aiming or squeezing can be effective.

🔷 Because the smoke is coming from an electrical outlet, the nurse must act quickly while keeping a safe exit route behind them.

🔷 Correct extinguisher technique helps control small fires while protecting staff and clients from injury and smoke exposure.

Use a Class B fire extinguisher.

🔷Class B is for flammable liquids (gasoline, oil), not electrical equipment.

🔷An outlet fire is an electrical (Class C) fire requiring the correct extinguisher type.

Aim the extinguisher's hose at the top of the flames.

🔷The nozzle should be aimed at the base of the fire to cut off the fuel source effectively.

🔷Aiming at the top can spread flames and reduce extinguishing success.

Use an up-and-down vertical motion to extinguish the fire.

🔷The correct technique is to sweep side-to-side across the base of the fire.

🔷Vertical motion is less effective and can miss the burning source area.

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Answer 5

Correct Answers

Blank 1 Correct Option: serotonin Syndrome
Blank 2 Correct Option: an interaction between citalopram and St. John's Wort

Rationale :

🔷 Citalopram is an SSRI that increases serotonin levels to treat depression, and effects may take 4–6 weeks to fully improve symptoms.

🔷 St. John’s Wort also increases serotonergic activity and can interact with SSRIs, causing dangerously high serotonin levels.

🔷 Combining these increases the risk for serotonin syndrome, a potentially life-threatening condition.

🔷 The nurse should recognize this as a priority medication-safety issue and instruct the client to stop the herb and notify the provider immediately.

🔷 Early signs include agitation, confusion, sweating, tachycardia, diarrhea, tremor, and hyperreflexia, which require urgent evaluation if present.

anticholinergic toxicity

🔷Anticholinergic toxicity is linked to medications with strong anticholinergic properties (e.g., TCAs, antihistamines), not SSRIs like citalopram.

🔷The key risk cue here is a serotonergic herb, not anticholinergic medication exposure.

severe neutropenia

🔷Severe neutropenia is most associated with certain antipsychotics (e.g., clozapine) and some chemotherapy agents, not citalopram or famotidine.

🔷 The client’s presentation and medication list do not support a high neutropenia risk.

metabolic syndrome

🔷Metabolic syndrome is commonly related to second-generation antipsychotics, long-term weight gain, and insulin resistance.

🔷While family history is important, it does not represent the immediate medication-related risk shown in this scenario.

hyperkalemia

🔷Hyperkalemia is typically linked to kidney disease or medications like ACE inhibitors, ARBs, and potassium-sparing diuretics.

🔷 None of the listed agents (citalopram, St. John’s Wort, famotidine) directly indicate hyperkalemia as the priority risk.

an adverse effect of famotidine

🔷Famotidine’s common effects (e.g., headache, mild GI changes) do not create the high-risk emergency pattern seen with serotonergic overload.

🔷It does not explain the major safety concern in this medication combination.

an interaction between citalopram and famotidine

🔷This combination is not the classic high-risk interaction in depression management compared with serotonergic herb use.

🔷The major danger in this case is adding St. John’s Wort to an SSRI.

a family history of type 2 diabetes mellitus

🔷Family history increases long-term cardiometabolic risk, but it does not identify the most urgent medication-related complication.

🔷 The scenario highlights an immediate interaction risk rather than chronic metabolic risk.

an adverse effect of citalopram

🔷While SSRIs can cause GI effects and insomnia, the client’s major risk comes from combining serotonergic agents.

🔷 The herb-SSRI interaction is more dangerous than typical SSRI side effects.

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Answer 6

Correct Answers:

Speech therapist

Rationale :

✅ A speech-language pathologist (speech therapist) is the specialist who evaluates and treats dysphagia because swallowing is a complex neuromuscular function.

✅ They perform a structured swallow assessment to identify aspiration risk and which textures/liquids are safest.

✅ They recommend diet modifications (e.g., thickened liquids, puree) and safe-swallow techniques (chin-tuck, small bites, pacing).

✅ They also guide swallowing exercises to improve oral-motor control and reduce choking episodes.

✅ Early referral helps prevent serious complications like aspiration pneumonia, malnutrition, and dehydration.

Occupational therapist

✅OT focuses on ADLs (dressing, feeding mechanics, adaptive devices) and functional independence.

✅While OT may help with self-feeding skills, they are not the primary provider for swallow physiology evaluation.

Respiratory therapist

✅RT manages airway/oxygenation, breathing treatments, and ventilatory support.

✅They do not assess the oral/pharyngeal swallowing mechanism or prescribe swallow strategies.

Pharmacist

✅Pharmacists focus on medication safety, interactions, and dosage optimization.

✅They can suggest alternate medication forms, but they do not perform swallow evaluations or therapy.

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Answer 7

Correct Answers:

"I should take this medication between meals."

Rationale :

💎 Taking ferrous sulfate between meals improves iron absorption because food can reduce absorption.

💎 Iron is absorbed best in an acidic environment, so taking it with vitamin C/juice can enhance effectiveness.

💎 This is important in pregnancy because iron supports maternal RBC production and fetal growth.

💎 The client should expect possible GI effects (constipation, nausea), and stools often become dark/greenish-black, not loose yellow.

💎 Correct timing helps prevent persistent iron-deficiency anemia, which can worsen fatigue and reduce oxygen-carrying capacity.

“I can take this medication with caffeinated beverages.”

💎Caffeine (and tea/coffee tannins) can decrease iron absorption.

💎Teaching should emphasize avoiding coffee/tea close to the iron dose.

“I should take this medication with milk.” (Incorrect):

💎Calcium in milk interferes with iron absorption and reduces the therapeutic benefit.

💎Iron should be separated from calcium-rich foods/supplements when possible.

“I might have loose, yellow stools while taking this medication.” (Incorrect):

💎Iron more commonly causes dark stools and constipation, not loose yellow stools.

💎Loose stools would require follow-up because it is not a typical expected effect.

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Answer 8

Correct Answers:

Obtain the client's blood glucose level.

Rationale :

🔷 Measuring a capillary blood glucose is a routine, noninvasive, standard procedure that can be safely delegated to an assistive personnel (AP).

🔷 This task follows a predictable step-by-step process and does not require clinical judgment or interpretation.

🔷 The nurse remains responsible for analyzing the result, recognizing abnormal values, and determining next actions.

🔷 Delegation supports safe workflow while ensuring the nurse focuses on assessment, teaching, and decision-making.

🔷 The nurse must confirm the AP reports the number promptly and documents according to policy.

Provide education on carbohydrate counting.

🔷 Teaching requires nursing knowledge and evaluation of understanding, which is RN scope.

🔷 It involves individualized instruction based on diet, meds, and glucose trends.

Interpret the need to administer insulin. (Incorrect):

🔷 Interpreting insulin need requires clinical judgment, assessment, and knowledge of protocols.

🔷APs cannot decide medication necessity or dosing.

Instruct the client on the use of a glucometer. (Incorrect):

🔷Teaching a client to use a glucometer is patient education, requiring assessment of readiness and return demonstration.

🔷This must be done by the nurse (or qualified educator), not AP.

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Answer 9

Correct Answers:

Blood pressure 144/92 mm Hg

Rationale :

🟣 A blood pressure of 144/92 mm Hg is elevated (hypertensive range) and requires follow-up because persistent hypertension increases risk for stroke, heart disease, and kidney damage.

🟣 The nurse should recheck the BP (correct cuff size, proper positioning, rest period) to confirm accuracy.

🟣 If confirmed, the nurse should assess for symptoms (headache, vision changes, chest pain) and review risk factors and medications.

🟣 Elevated BP often requires provider notification and a plan for lifestyle modification and/or treatment.

🟣 Early identification is key because hypertension can be silent yet cause long-term complications.

Temperature 37.7° C (100° F)

🟣This is a low-grade elevation and may occur with mild illness, exertion, or environmental factors.

🟣It may warrant monitoring and symptom assessment, but it is less urgent than a hypertensive BP reading.

Respiratory rate 12/min

🟣12/min is within the normal adult range (12–20/min).

🟣Follow-up is not required unless paired with abnormal work of breathing or altered mental status.

Oxygen saturation 96%

🟣96% is generally a normal SpO₂ for most clients on room air.

🟣No immediate follow-up is needed without respiratory distress or chronic lung disease considerations.

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Answer 10

Correct Answers:

The client is submissive to others.

Rationale :

🔶 Dependent personality disorder is characterized by an excessive need to be taken care of, leading to submissive and clinging behavior.

🔶 Clients often have difficulty making everyday decisions without reassurance and may fear abandonment.

🔶 They commonly allow others to assume responsibility for major areas of life because of low self-confidence.

🔶 They may tolerate poor treatment to maintain support due to intense separation anxiety.

🔶 Recognizing this pattern helps guide interventions that build assertiveness and independent coping.

The client exhibits splitting behaviors.

🔶Splitting (idealizing/devaluing others) is more associated with borderline personality disorder.

🔶It reflects unstable relationships rather than submissive dependence.

The client is preoccupied with orderliness.

🔶Preoccupation with orderliness/perfectionism aligns with obsessive-compulsive personality disorder (OCPD).

🔶That pattern centers on control and rigidity, not reliance on others.

The client is suspicious of others.

🔶Suspiciousness and mistrust align with paranoid personality disorder.

🔶Dependent PD is typically fear-based and approval-seeking rather than mistrustful.

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QLexNursing

1 :
A nurse on a mental health unit is assisting with the admission of a client.

Correct Answers

2 :
A nurse in a long-term care facility is contributing to the plan to control the spread of Escherichia coli among the residents. Which of the following actions should the nurse include?

3 :
A nurse is assisting in the care of a toddler in the outpatient setting.

Correct Answers

4 :
A nurse discovers smoke coming from an outlet in the hallway. After activating the fire alarm, the nurse prepares to use a fire extinguisher. Which of the following actions should the nurse take?

5 :
A nurse in an outpatient mental health clinic is assisting in the care of a client.

Correct Answers

6 :
A nurse is collecting data from a client who is reporting difficulty swallowing. Which of the following referrals should the nurse anticipate?

7 :
A nurse is reinforcing teaching with a client who is at 28 weeks of gestation and has a new prescription for ferrous sulfate PO. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is contributing to the plan of care for a client who has a new diagnosis of diabetes mellitus. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

9 :
A nurse in an outpatient clinic is reviewing the vital signs of a client. Which of the following findings requires follow-up by the nurse?

10 :
A nurse is collecting data from a client who has dependent personality disorder. Which of the following findings should the nurse expect?

QLexNursing

1 : A nurse on a mental health unit is assisting with the admission of a client.

Correct Answers

2 : A nurse in a long-term care facility is contributing to the plan to control the spread of Escherichia coli among the residents. Which of the following actions should the nurse include?

3 : A nurse is assisting in the care of a toddler in the outpatient setting.

Correct Answers

4 : A nurse discovers smoke coming from an outlet in the hallway. After activating the fire alarm, the nurse prepares to use a fire extinguisher. Which of the following actions should the nurse take?

5 : A nurse in an outpatient mental health clinic is assisting in the care of a client.

Correct Answers

6 : A nurse is collecting data from a client who is reporting difficulty swallowing. Which of the following referrals should the nurse anticipate?

7 : A nurse is reinforcing teaching with a client who is at 28 weeks of gestation and has a new prescription for ferrous sulfate PO. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is contributing to the plan of care for a client who has a new diagnosis of diabetes mellitus. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

9 : A nurse in an outpatient clinic is reviewing the vital signs of a client. Which of the following findings requires follow-up by the nurse?

10 : A nurse is collecting data from a client who has dependent personality disorder. Which of the following findings should the nurse expect?

1 :
A nurse on a mental health unit is assisting with the admission of a client.

2 :
A nurse in a long-term care facility is contributing to the plan to control the spread of Escherichia coli among the residents. Which of the following actions should the nurse include?

3 :
A nurse is assisting in the care of a toddler in the outpatient setting.

4 :
A nurse discovers smoke coming from an outlet in the hallway. After activating the fire alarm, the nurse prepares to use a fire extinguisher. Which of the following actions should the nurse take?

5 :
A nurse in an outpatient mental health clinic is assisting in the care of a client.

6 :
A nurse is collecting data from a client who is reporting difficulty swallowing. Which of the following referrals should the nurse anticipate?

7 :
A nurse is reinforcing teaching with a client who is at 28 weeks of gestation and has a new prescription for ferrous sulfate PO. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is contributing to the plan of care for a client who has a new diagnosis of diabetes mellitus. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

9 :
A nurse in an outpatient clinic is reviewing the vital signs of a client. Which of the following findings requires follow-up by the nurse?

10 :
A nurse is collecting data from a client who has dependent personality disorder. Which of the following findings should the nurse expect?