an adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder after starting medication therapy the nurse n
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Quizlet

1. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. After starting medication therapy, the nurse notices the client has more energy, is giving away her belongings, and has an elevated mood. Which intervention is best for the nurse to implement?

Correct answer: B

Rationale: When a client with major depressive disorder shows signs of increased energy, giving away belongings, and an elevated mood, it could indicate a shift towards suicidal behavior. Therefore, the best intervention for the nurse is to ask the client if she has had any recent thoughts of harming herself. This is crucial to assess the client's risk for suicide and provide necessary interventions. Choices A, C, and D are incorrect because they do not address the potential risk of harm to the client and do not prioritize the immediate assessment required in this situation.

2. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?

Correct answer: C

Rationale: In a client with cirrhosis presenting with jaundice and ascites, yellowing of the skin (icterus) is the most concerning assessment finding. This indicates significant liver dysfunction and a high level of bilirubin in the blood. Yellowing of the skin suggests a severe impairment of the liver's ability to process bilirubin, which can lead to serious complications. Peripheral edema and increased abdominal girth are common manifestations of cirrhosis but are not as acutely concerning as skin yellowing. Confusion and altered mental status are also critical findings in cirrhosis, indicating hepatic encephalopathy, but skin yellowing is more closely associated with the severity of liver dysfunction in this scenario.

3. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?

Correct answer: C

Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.

4. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which assessment finding should be reported to the healthcare provider immediately?

Correct answer: C

Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis as it may indicate an underlying infection, which can lead to serious complications in this population. Elevated body temperature can be a sign of sepsis, which requires immediate attention to prevent further deterioration. Reporting this finding promptly allows for timely intervention. Choices A, B, and D are within normal ranges and do not pose an immediate threat to the client's well-being in the context of preparing for hemodialysis.

5. A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?

Correct answer: C

Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.

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