the nurse is developing a care plan for a client with depression what should be included in the plan
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Nursing Elites

HESI LPN

Adult Health 2 Final Exam

1. The healthcare professional is developing a care plan for a client with depression. What should be included in the plan?

Correct answer: D

Rationale: A comprehensive care plan for a client with depression should include multiple components to address various aspects of health. Regular physical activity can help improve mood and overall well-being. Scheduled sleep patterns are essential as sleep disturbances are common in depression and can worsen symptoms. Social interaction with family and friends provides emotional support and reduces feelings of isolation. Therefore, including all these aspects in the care plan can help support the client's recovery. Choice D, 'All of the above,' is the correct answer because all the options are important components of a holistic care plan for depression. Choices A, B, and C are incorrect because each of these elements plays a crucial role in managing depression.

2. The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?

Correct answer: C

Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.

3. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?

Correct answer: C

Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.

4. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?

Correct answer: C

Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.

5. Which structures are located in the subcutaneous layer of the skin?

Correct answer: D

Rationale: The correct answer is D: Adipose cells and blood vessels. The subcutaneous layer, also known as the hypodermis, primarily consists of adipose (fat) tissue and blood vessels. Adipose tissue provides insulation, energy storage, and cushioning, while blood vessels supply nutrients and oxygen. Sebaceous and sweat glands are located in the dermis, which is the layer beneath the epidermis. Melanin and keratin are components of the epidermis, responsible for skin color and waterproofing, respectively. Sensory receptors and hair follicles are found in the dermis and extend into the subcutaneous layer but are not exclusive to it.

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