Question

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

Answer 1

Correct Answers

Blank 1 Correct Option: suicidal ideation
Blank 2 Correct Option: Hopelessness

Rationale :

🌸 Suicidal ideation is the priority risk because the client expresses thoughts indicating a desire not to continue living, stating, “I wish I weren’t here.”

🌸 The client has multiple significant risk factors for suicide, including a previous suicide threat, recent relationship loss, job loss, social withdrawal, and a family history of major depressive disorder.

🌸 The client’s statement reflects hopelessness, which is one of the strongest predictors of suicide risk because the person may feel there is no possibility for improvement.

🌸 The client’s depressed mood, flat affect, worthlessness, and withdrawal from support systems further increase concern for self-harm risk.

🌸 Because the client has expressed suicidal thoughts and is already placed on one-on-one observation, immediate safety monitoring and suicide precautions are appropriate interventions.

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Answer 2

Correct Answers:

Frozen fruit

Rationale :

🌻 Plain frozen fruit is naturally very low in sodium because fruits generally contain minimal amounts of sodium unless salt or sodium-containing additives are added.

🌻 A client prescribed a 2-gram sodium diet should prioritize fresh or minimally processed foods because processing often adds significant sodium.

🌻 Frozen fruit without sauces, syrups, or added ingredients can provide vitamins, minerals, fiber, and antioxidants while helping the client remain within the daily sodium restriction.

🌻 Choosing low-sodium foods is important in hypertension because excessive sodium can contribute to fluid retention and increased blood pressure in salt-sensitive individuals.

🌻 Therefore, among the foods listed, plain frozen fruit has the lowest sodium content and is the best recommendation.

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Answer 3

Correct Answers

Blank 1 Correct Option: Major depressive disorder
Blank 2 Correct Option: Remain in the room with the client and Assist the client to identify stressors.
Blank 3 Correct Option: Suicidal ideation and Sleep patterns.

Rationale :

Condition

Major depressive disorder

🏵️ The client demonstrates several findings consistent with major depressive disorder, including a flat affect, poor hygiene, social withdrawal, fatigue, and hopelessness.

🏵️ The statement that “life is not worth living” is especially concerning because it reflects significant hopelessness and possible suicidal thinking.

🏵️ The client also reports a major psychosocial loss, specifically losing their job 6 months ago, which can contribute to or worsen depressive symptoms.

🏵️ A family history of mood disorders further increases the client’s risk for developing a depressive disorder.

🏵️ Although alcohol use may worsen the clinical presentation, the overall pattern most strongly supports major depressive disorder with significant suicide risk.

Actions

Remain in the room with the client

🏵️ Remaining with the client promotes immediate safety, especially because the client has expressed that life is not worth living.

🏵️ Such statements can indicate suicidal ideation, even when the client has not yet described a specific plan.

🏵️ A potentially suicidal client should not be left alone until the level of suicide risk has been fully assessed and appropriate precautions are established.

🏵️ The nurse’s presence also provides support, reassurance, and an opportunity for therapeutic communication during a period of severe emotional distress.

🏵️ Therefore, staying with the client is a priority intervention because preserving life and preventing self-harm take precedence over other needs.

Assist the client to identify stressors

🏵️ Helping the client identify current stressors supports assessment of factors contributing to depressive symptoms and hopelessness.

🏵️ In this case, major stressors include job loss, impaired functioning, alcohol use, and possible financial or relationship difficulties.

🏵️ Identifying stressors allows the nurse and client to begin developing more effective coping strategies and realistic problem-solving approaches.

🏵️ This intervention can also help the client recognize links between stressful events, emotional responses, and maladaptive coping behaviors such as alcohol use.

🏵️ Therefore, assisting the client to identify stressors is an appropriate therapeutic intervention once immediate safety is maintained.

Parameters

Suicidal ideation

🏵️ The client’s statement that life is not worth living indicates possible suicidal ideation and requires continued, direct assessment.

🏵️ Suicide risk should be evaluated for thoughts, intent, plan, access to means, previous attempts, and protective factors.

🏵️ Depressive symptoms combined with hopelessness and substance use further increase the likelihood of self-harm.

🏵️ Monitoring suicidal ideation helps determine whether safety interventions need to be maintained, increased, or modified.

🏵️ Therefore, changes in the frequency or intensity of suicidal thoughts are an essential measure of the client’s progress and safety.

Sleep patterns

🏵️ Sleep disturbance is a common manifestation of major depressive disorder and may include insomnia, early-morning awakening, or excessive sleeping.

🏵️ Changes in sleep can provide useful information about the severity and progression of depressive symptoms.

🏵️ Improvement in sleep may indicate that treatment interventions are beginning to improve the client’s mood, energy, and overall functioning.

🏵️ Persistent sleep disturbance can also worsen fatigue, concentration difficulties, emotional distress, and suicide risk.

🏵️ Therefore, monitoring the client’s sleep pattern is an appropriate way to evaluate progress during treatment for depression.

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Answer 4

Correct Answers:

An adolescent who has cystic fibrosis and is receiving their yearly tune-up

Rationale :

✍️ During disaster preparation, the nurse should identify clients who are stable and can safely continue care outside the acute-care setting.

✍️ An adolescent receiving a routine cystic fibrosis “tune-up” is generally more clinically stable than clients requiring intensive monitoring or emergency treatment.

✍️ Discharging a stable client helps create available beds, staff, and equipment for people who may arrive with storm-related emergencies or critical conditions.

✍️ The adolescent’s care can often be continued with outpatient follow-up, medications, respiratory treatments, and family support, depending on clinical stability.

✍️ Therefore, the adolescent receiving a scheduled yearly tune-up is the best candidate for discharge planning among the clients listed.

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Answer 5

Correct Answers:

Include the client's input when setting treatment goals.

Rationale :

♦️ Autonomy is the ethical principle that supports a client's right to make informed decisions about their own health care.

♦️ Including the client in treatment planning allows the person to express personal values, preferences, priorities, and goals of care.

♦️ This is particularly important in terminal illness, when choices may involve comfort-focused care, symptom management, treatment limitations, or end-of-life preferences.

♦️ The nurse should support informed decision-making while respecting the client's right to accept, refuse, or modify treatment options.

♦️ Therefore, involving the client directly in setting treatment goals is the action that most clearly promotes autonomy and self-determination.

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Answer 6

Correct Answers:

Report any IV infusion alarms..

Rationale :

🖍️ Assistive personnel may perform routine, noninvasive tasks and report abnormal findings or equipment alarms to the licensed nurse.

🖍️ Reporting an IV pump alarm does not require the AP to assess the IV site, interpret the cause, or independently modify the infusion.

🖍️ Once the alarm is reported, the nurse must assess the situation because IV therapy requires clinical judgment and nursing responsibility.

🖍️ The AP should not silence, troubleshoot, or adjust the infusion independently because doing so may alter the prescribed treatment.

🖍️ Therefore, reporting IV infusion alarms is the most appropriate task to delegate to assistive personnel.

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Answer 7

Correct Answers:

Prepare to administer oxygen via Venturi face mask.
Examine the client's nail beds.
Encourage client to perform deep breathing exercises.

Rationale :

Prepare to administer oxygen via Venturi face mask

✏️ The client’s oxygen saturation has progressively decreased from 94% to 90% despite increasing nasal-cannula oxygen from 2 L/min to 4–5 L/min, indicating inadequate oxygenation with the current device.

✏️ The provider prescription requires maintaining an oxygen saturation greater than 92%, so escalation of oxygen delivery is appropriate when the nasal cannula is not achieving the prescribed target.

✏️ A Venturi mask can deliver a more precise and higher concentration of oxygen than a standard low-flow nasal cannula.

✏️ In the PACU, worsening hypoxemia after sedation can result from hypoventilation, airway obstruction, or atelectasis, so the nurse should promptly increase respiratory support while continuing assessment.

✏️ Therefore, preparing to use a Venturi face mask is an appropriate action when oxygen saturation remains below the prescribed goal despite increasing nasal-cannula flow.

Examine the client’s nail beds

✏️ Examination of the nail beds helps assess for cyanosis and peripheral perfusion, both of which can provide additional information about oxygenation status.

✏️ Although pulse oximetry gives an objective oxygen-saturation measurement, the nurse should also perform a focused physical assessment rather than relying only on the monitor.

✏️ Bluish discoloration of the nail beds can indicate significant hypoxemia, especially when accompanied by declining oxygen saturation.

✏️ Assessment should also include skin color, respiratory effort, level of consciousness, and breath sounds because changes may signal worsening respiratory compromise.

✏️ Therefore, examining the nail beds is an appropriate component of the client’s ongoing oxygenation assessment.

Encourage client to perform deep breathing exercises

✏️ Following sedation, clients can develop shallow breathing and atelectasis, which reduce ventilation and contribute to decreased oxygen saturation.

✏️ Deep breathing promotes alveolar expansion and improves ventilation to areas of the lungs that may be partially collapsed.

✏️ Encouraging the client to take slow, deep breaths can improve oxygen exchange and postoperative respiratory function.

✏️ This intervention is especially useful when the client is sufficiently arousable and able to follow commands, as this client is.

✏️ Therefore, deep breathing exercises are an appropriate noninvasive intervention to improve oxygenation in the PACU.

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Answer 8

Correct Answers:

"Label the door to the bathroom with a symbol."

Rationale :

🖊️ Clients with dementia often have memory loss, impaired recognition, and difficulty navigating familiar environments, so clear visual cues can improve independence.

🖊️ Labeling the bathroom door with a simple picture or recognizable symbol helps the client identify its purpose even when reading ability or word recognition declines.

🖊️ Environmental cues should be simple, consistent, and easy to understand to reduce confusion and frustration.

🖊️ Using symbols can also support safer toileting by decreasing the likelihood that the client will become lost, incontinent, or distressed while searching for the bathroom.

🖊️ Therefore, placing a clear visual symbol on the bathroom door is an appropriate and practical home-management strategy for a client with dementia.

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Answer 9

Correct Answers

Prepare the child for an endoscopic exam. [ Anticipated ]
Monitor the child's respiratory status frequently. [ Anticipated ]
Encourage the child to consume soft foods. [ Contraindicated ]
Examine each stool the child passes. [ Nonessential ]
Place nasogastric tube to low-Intermittent suction. [ Contraindicated ]

Rationale :

Prepare the child for an endoscopic exam — ANTICIPATED

🔆 The radiograph confirms that a 2.69-cm foreign object is lodged in the esophagus, rather than progressing normally through the gastrointestinal tract.

🔆 Because the child was eating fish and reports a sticking sensation, the object is likely a sharp fish bone, which can injure or perforate the esophageal wall.

🔆 The presence of blood-tinged mucus, gagging, vomiting, and surrounding swelling indicates active irritation and increases the need for prompt removal.

🔆 Endoscopy allows direct visualization and controlled removal of an esophageal foreign body while assessing the surrounding tissue for injury.

🔆 Therefore, preparing the child for urgent endoscopic evaluation and removal is an anticipated prescription.

Monitor the child’s respiratory status frequently — ANTICIPATED

🔆 The child has stridor and wheezing, which indicate that the foreign body or surrounding edema may be affecting the airway.

🔆 Esophageal swelling can place pressure on nearby airway structures, and deterioration can occur rapidly in a young child.

🔆 Frequent respiratory assessment should include respiratory rate, effort, breath sounds, oxygen saturation, stridor, and level of consciousness.

🔆 Increasing stridor, retractions, cyanosis, or decreasing oxygen saturation can indicate impending airway compromise requiring immediate intervention.

🔆 Therefore, frequent monitoring of the child’s airway and respiratory status is an anticipated and high-priority prescription.

Encourage the child to consume soft foods — CONTRAINDICATED

🔆 A child with a foreign body lodged in the esophagus should remain NPO until the object has been safely removed and swallowing is reassessed.

🔆 Giving food could force the sharp object deeper into the esophageal wall and worsen mucosal trauma, bleeding, or perforation.

🔆 The child is already experiencing gagging, vomiting, excessive secretions, and blood-tinged mucus, demonstrating impaired safe swallowing.

🔆 Oral intake also increases the risk for aspiration, particularly if airway compromise or sedation for endoscopy becomes necessary.

🔆 Therefore, encouraging soft foods is contraindicated until the foreign body is removed and the provider confirms that oral intake is safe.

Examine each stool the child passes — NONESSENTIAL

🔆 Stool monitoring is useful when a small, blunt foreign body has already passed into the stomach or intestines and is expected to pass spontaneously.

🔆 In this case, imaging clearly demonstrates that the object remains lodged in the esophagus.

🔆 The child is also symptomatic with stridor, gagging, vomiting, bleeding, and local swelling, making observation for spontaneous passage inappropriate.

🔆 The object requires direct removal rather than waiting for it to appear in the stool.

🔆 Therefore, examining every stool is nonessential in the immediate management of this child.

Place nasogastric tube to low-intermittent suction — CONTRAINDICATED

🔆 Passing a nasogastric tube through an esophagus containing a sharp lodged foreign body can displace the object or push it further into injured tissue.

🔆 Manipulation can increase the risk for esophageal perforation, hemorrhage, and additional mucosal damage.

🔆 The radiograph already shows swelling at the points of contact, suggesting that local tissue injury is occurring.

🔆 Gastric decompression does not treat the primary problem because the obstruction is caused by a foreign body requiring endoscopic removal.

🔆 Therefore, inserting an NG tube before the object is removed is contraindicated unless specifically directed under controlled specialist management.

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Answer 10

Correct Answers:

Ensure the device is kept below the level of the client's chest.

Rationale :

🧿 The chest drainage system should be kept below the level of the client’s chest to promote drainage by gravity and prevent fluid from flowing backward into the pleural space.

🧿 Keeping the system dependent helps maintain the intended one-way drainage of air and fluid from the thoracic cavity.

🧿 If the drainage unit is raised above chest level, pleural contents can potentially re-enter the chest, increasing the risk of complications.

🧿 The tubing should also remain free of kinks, dependent loops, or compression so that drainage and suction are not impaired.

🧿 Therefore, maintaining the chest drainage device below chest level at all times is a key safety intervention for a client with a pneumothorax.

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Provider Prescription	Anticipated	Nonessential	Contraindicated
Prepare the child for an endoscopic exam.
Monitor the child's respiratory status frequently.
Encourage the child to consume soft foods.
Examine each stool the child passes.
Place nasogastric tube to low-Intermittent suction.

QLexNursing

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

Correct Answers

2 :
A nurse is caring for a client who has hypertension and a prescription for a 2-gram sodium diet. Which of the following foods should the nurse recommend as having the lowest amount of sodium?

3 :
A nurse is assisting with the care of a client.

Correct Answers

4 :
A nurse is preparing for an incoming storm. Which of the following clients should the nurse recommend for discharge planning?

5 :
A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse cake to promote the client's autonomy?

6 :
A nurse is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?

7 :
A nurse is assisting with the care of a client in a PACU.

Answer Options

8 :
A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is assisting in the care of a child.

Correct Answers

10 :
A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

QLexNursing

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

Correct Answers

2 : A nurse is caring for a client who has hypertension and a prescription for a 2-gram sodium diet. Which of the following foods should the nurse recommend as having the lowest amount of sodium?

3 : A nurse is assisting with the care of a client.

Correct Answers

4 : A nurse is preparing for an incoming storm. Which of the following clients should the nurse recommend for discharge planning?

5 : A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse cake to promote the client's autonomy?

6 : A nurse is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?

7 : A nurse is assisting with the care of a client in a PACU.

Answer Options

8 : A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

9 : A nurse is assisting in the care of a child.

Correct Answers

10 : A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

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

2 :
A nurse is caring for a client who has hypertension and a prescription for a 2-gram sodium diet. Which of the following foods should the nurse recommend as having the lowest amount of sodium?

3 :
A nurse is assisting with the care of a client.

4 :
A nurse is preparing for an incoming storm. Which of the following clients should the nurse recommend for discharge planning?

5 :
A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse cake to promote the client's autonomy?

6 :
A nurse is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?

7 :
A nurse is assisting with the care of a client in a PACU.

8 :
A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is assisting in the care of a child.

10 :
A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?