Exam (elaborations) NURS 2539 (NURS 2539) NURS 2539 CLINICAL DECISION MAKING/ CLINICAL JUDGEMENT

CLINICAL DECISION MAKING/ CLINICAL JUDGEMENT Question 1 See full question 37s After learning that a roommate is HIV-positive, a client asks a nurse about moving to another room on the psychiatric unit because he no longer feels "safe." What should the nurse do first? You Selected:  Ask the client to describe his fears. Correct response:  Ask the client to describe his fears. Explanation: Remediation: Question 2 See full question 1m 3s A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? You Selected:  The client will show no self-harm or harm to staff. Correct response:  The client will show no self-harm or harm to staff. Explanation: Remediation: Question 3 See full question 28s The nurse starts an infusion of tissue plasminogen activase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication? You Selected:  Frequent neurologic assessment is necessary to determine whether the stroke is evolving or acute complications are developing. Correct response:  Frequent neurologic assessment is necessary to determine whether the stroke is evolving or acute complications are developing. Explanation: Remediation: Question 4 See full question 31s A client is a gravida 2 para 1 and is currently 12 weeks gestation. She states that she drank beer throughout her last pregnancy. The client asks the nurse if it is okay to have a few drinks during this current pregnancy. Which of the following responses by the nurse would be most appropriate?