Question

1. A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Exhibit)

1. Encourage the client to verbalize feelings.
2. Implement seizure precaution for the client.
3. Administer ondansetron to the client for nausea.
4. Obtain the client’s weight.

2. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse?

1. A client who lives with family members and begins to take more responsibility for self-care
2. A client who reports being given sedative medications by family members
3. A client who is taking warfarin and has several small bruises on her shins and hands
4. A client who schedules multiple visits with his provider every month

3. A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

1. Administer medications intramuscularly.
2. Provide a diet low in protein.
3. Observe for bruising of the skin.
4. Monitor vital signs every hour for the first 4 hr.

4. A nurse is caring for a client who is postoperative following an appendectomy and is receiving gentamicin. Which of the following assessment findings should the nurse identify as an adverse effect of this medication?

1. Creatinine 2.3 mg/dL
2. Respiratory rate 22/min
3. 2+ pitting edema of the ankles
4. Hgb 8.7 g/dL

5. A nurse is an acute care facility is caring for a client who is homeless a has a decubitus ulcer. Which of the following actions should the nurse take as a client advocate?

1. Gather dressing supplies for the client’s discharge.
2. Provide client teaching about nutrition.
3. Consult with the facility’s quality improvement team.
4. Contact the facility’s case management department.

Answer 1

●.A patient who is with major depressive disorder often experience symptoms of feeling depressed, lack of interest, social interaction, loss of appetite or eat in excess,isolate themselves, weight loss ,mood swings ,etc.,

They dont exhibit nausea

Verbalisation will be effective as the next part of weight checkup to rule put weight loss or gain

Antiemetics will be needed if patient has nausea

Seizure is not a symptom of major depressive

Ans:Obtain client's weight

●Giving responsibility is a sort of respect

A client if given sedatives by family members without prescription or provider's order can happen if the family members feel that the elders are a trouble for them. It is a way of abusing

Bruises is a side effect of warfarin,so it is not elder abuse

Multiple visits are common in elderly patients in a month

Ans:A client who reports being given sedative medications by family members

● Altepase should be administered intravenously

Bruises are uncommon

Normal diet is indicated

Blood pressure variation can be observed so it has to be assessed every 15 minutes

Ans:Monitor vital signs every hour for the first 4 hour

●The major side effect of gentamicin is it can affect the renal system so all renal values has to be monitored before administering

Respiratory rate is normal

Hemoglobin if 8.7 g/dL

Edema as to be ruled out of renal or cardiac dysfunction

Ans:Creatinine 2.4mg/dL