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NURS 4203 questions with correct answers.
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NURS 4203 questions with correct answers.
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NURS 4203 questions with correct answersStatistically speaking, which two patients do you predict are at greatest
risk for suicide?
Ms. R, a 22-year-old grad student who is engaged
Mr. M, a 34-year-old male with multiple sclerosis
Mr. A, a 68-year-old Vietnam veteran with TBI
Ms. G, a 25-year-old single Navajo mother who struggles with alcohol
Correct Answer-Mr. A, a 68-year-old Vietnam veteran with TBI
Ms. G, a 25-year-old single Navajo mother who struggles with alcohol
explanation
though every patient who presents with possible suicidal ideation should
be assessed equally, there may be additional risks for (a) veterans,
especially with TBI (special risks); (b) older men (4 times as likely); (c)
young American Indian adults (2.5 times more likely than their peers);
and (d) those with mood disorders, (50%) and those who abuse alcohol
(25%).
A patient has committed suicide while under team care in your facility.
A coworker says, "Why are we being called to a 'postmortem' meeting?
We didn't do anything wrong." Which is your best explanation?
There is almost always litigation after an inhouse suicide, and it only
makes sense that someone must be held responsible.
Staff are at high-risk for hurting themselves after a suicide.
,It's important that the entire team collaborate to make documentation say
the right things.
A postmortem assessment can help the team determine any changes that
might be made in agency protocol to improve safety. Correct Answer-A
postmortem assessment can help the team determine any changes that
might be made in agency protocol to improve safety.
Mrs. Chauncey, 80 years old, is taking a selective
serotonin reuptake inhibitor (SSRI) and Tylenol PM daily
plus other medications. She has multiple, vague somatic
complaints. This morning she complains of a "stomach
ache" and "gas." What is your best initial nursing response?
A.
Tell her to increase her water intake.
B.
Perform a digital rectal examination for impaction.
C.
Document the complaint of abdominal pain.
D.
Assess bowel sounds in all four quadrants. Correct Answer-Answer D
Rationales
,A. An increase in water intake may be an excellent intervention for an
older patient as long as no fluids are restricted and no swallowing
problems are evident.
B. A digital rectal examination without further assessment is
inappropriate and can be traumatic for the patient.
C. Documenting a patient's complaint is appropriate as long as the
intervention and evaluation are also completed and documented.
D.Assessing bowel sounds is the best
initial response. Older adults are at risk for constipation, and some
medications can cause constipation. Mrs. Chauncey is taking an SSRI
and Tylenol PM, which contains diphenhydramine.
Mrs. Chauncey, 80 years of age, complains of stomach pain and is now
mute and staring out of her window. She is refusing food. Which of the
following interventions are appropriate? (Select all that apply.)
A.Give her privacy, and close her door.
B.Speak with her, although she may not answer.
C.Continue to offer her food and fluids.
D.Regularly assess vital signs and skin turgor Correct Answer-Answer
BCD
Rationales
A.Isolating Mrs. Chauncey is inappropriate. You need to be aware that
older adults may experience increased depression while hospitalized.
Although frail, Mrs. Chauncey may have energy to harm herself, even
superficially.
, B.Sitting with Mrs. Chauncey and speaking to her lets her know you are
available.
C.You are legally and ethically responsible to offer patients regular food
and fluids whether they accept them or not.
D.Vital signs are an important regular assessment, as well as skin turgor
assessment. The older adult who is depressed is at risk for dehydration
and possible hypotension.
Mrs. Chauncey receives a visit from her priest. He runs out of her room
and then pulls the nurse assistant back into her room. Mrs. Chauncey is
cutting her left wrist (superficially) with the 5 x 7 glass from a framed
photo of a grandchild. She is taken to the emergency department, where
her wrist is bandaged. Her daughter and son-in-law are notified. As her
nurse, which of the following statements help clarify what has taken
place?
A."Don't worry, I think your mom is just confused."
B."Your mom has been more withdrawn over the last few days."
C. "I am very concerned that your mom is suicidal."
D. "When your mom's priest arrived, he found her cutting her wrist with
the glass from a framed photo." Correct Answer-Answer D
A.This statement offers false reassurance.
B.Although true, this statement does not give the family a clear picture
of the events.
C.You may suspect suicidal ideation, but until Mrs. Chauncey is further
assessed, you should not state your suspicions.
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