The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST?
1. A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worth
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The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST?
1. A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness.
2. A patient indicates an intent to kill himself and says he has access to a gun.
3. A patient had a miscarriage last evening and is experiencing anger and resentment.
4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.
Strategy: "FIRST" indicates priority.
1) need to assess physical needs and examine patient; second patient to see
2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry out threat
3) allow client to verbalize feelings
4) allow client to verbalize feelings
The nurse in a small town is called to a neighbor's house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions?
1. Time the frequency of the contractions.
2. Assess the type of vaginal discharge.
3. Monitor the strength of the contractions.
4. Observe the perineum.
Strategy: Assess before implementing.
1) priority is assessing if baby is crowning
2) priority is assessing if baby is crowning
3) labor is not the priority; nurse should determine if the birth is imminent
4) CORRECT— baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant's head; apply slight pressure to control delivery
The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST?
1. Contact the nursing supervisor.
2. Tell the emergency management team they will have to re-route 25 victims.
3. Activate the hospital's disaster plan.
4. Inform the emergency department nurses they must work overtime.
Strategy: "FIRST" indicates priority.
1) CORRECT— nurse must follow chain of command
2) not the nurse's responsibility
3) must notify immediate supervisor about the call; disaster plans are hospital policies that detail how nurses are to perform duties
4) not the responsibility or role of the nurse
As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?"
1. "This medication helps me with my depression."
2. "I will notify my physician if I show signs of hyperactivity and mania."
3. "I will see improvement in my symptoms in 1 to 4 weeks."
4. "If I experience a fever I will take Tylenol."
Strategy: "Further teaching is necessary" indicates incorrect information.
1) Celexa is a selective serotonin reuptake inhibitor (SSRI) used to treat depression
2) side effects: mania, hypomania, insomnia, impotence, headache, and dry mouth
3) true statement
4) correct— should notify physician immediately to assess for serotonin syndrome, which is a rare, life threatening event caused by SSRIs; symptoms include abdominal pain, fever, sweating, tachycardia, hypertension, delirium, myoclonus, irritability, and mood changes; may result in death
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