Nokea
Which of the following actions should the nurse take?
- A. Refer the adolescent to a local mental health clinic.
- B. Advise the adolescent to place the newborn for adoption
- C. Contact the adolescent's parent for assistance
- D. Assist the adolescent in applying for Medicaid
Correct Answer: D
Rationale: Medicaid can provide financial assistance for prenatal care and delivery.
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Which of the following positions should the nurse take to place the client at ease?
- A. Sit in a chair next to the bed
- B. Stand at the side of the bed.
- C. Sit on the bed next to the client.
- D. Stand at the foot of the bed
Correct Answer: A
Rationale: The correct answer is A: Sit in a chair next to the bed. This position allows the nurse to be at eye level with the client, promoting a sense of equality and rapport. Sitting also conveys a sense of attentiveness and availability for conversation. Standing at the side of the bed (B) may create a sense of distance. Sitting on the bed next to the client (C) may invade personal space. Standing at the foot of the bed (D) can be perceived as intimidating.
The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Petechiae and ecchymoses suggest thrombocytopenia warranting platelet count evaluation.
Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?(Select all that apply.)
- A. Give the client one simple direction at a time
- B. Refute the client's delusions using logic
- C. Allow the client to choose among a variety of activities each day
- D. Reinforce orientation to time, place, and person
- E. Establish eye contact when communicating with the client.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is essential for someone with dementia to reduce confusion and facilitate understanding.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce disorientation.
E: Establishing eye contact when communicating with the client enhances connection and understanding, aiding in effective communication.
Incorrect Choices:
B: Refuting the client's delusions using logic may lead to frustration and agitation, as individuals with dementia may not be able to understand or accept logical arguments.
C: Allowing the client to choose among a variety of activities each day may overwhelm them with choices, leading to increased confusion and agitation.
A nurse is admitting a client who has schizophrenia. The client state nurse to state?"I'm hearing voices. Which of the following responses is the priority for the nurse to state"
- A. What are the voices telling you?
- B. I realize the voices are real to you, but I don't hear anything.â€
- C. Have you taken your medication today?â€
- D. How long have you been hearing the voices?
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response shows active listening and encourages the client to express their thoughts, helping the nurse assess the content and potential danger of the voices. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than immediate safety, and choice D is relevant but does not address the immediate concern.