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Which nursing actions will best protect the client's safety? Select all that apply.
- A. Station a security guard outside the client's room at all times.
- B. Remove all cords, wires, and strings in the room.
- C. Provide paper dishes and plastic utensils.
- D. Assess whether the client has swallowed all medications.
- E. Ask a family member to stay with the client during the night.
- F. Check in on the client every 30 minutes.
Correct Answer: B,C,D,F
Rationale: Removing potential hazards, using safe utensils, ensuring medication compliance, and frequent checks minimize suicide risk by reducing means and monitoring behavior.
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When the counselor asks the members of the post-traumatic stress disorder (PTSD) support group to draw pictures of their traumatic experiences, the nurse understands that the primary purpose for drawing is to achieve what outcome?
- A. Deal consciously with painful memories
- B. Bond with other group members
- C. Receive approval from group members
- D. Justify participation in the group
Correct Answer: A
Rationale: Drawing traumatic experiences externalizes memories, helping clients confront and process painful events in a controlled, therapeutic way.
Which approach is best for managing the client's care?
- A. Use a nonjudgmental manner when cleaning the client of stool.
- B. Ask the client's spouse to perform hygiene measures.
- C. Hold the client responsible for all hygiene.
- D. Assign same-gender nurses to care for the client.
Correct Answer: A
Rationale: A nonjudgmental approach preserves the client's dignity, reducing embarrassment and supporting self-esteem during hygiene care.
When the client begins crying and says, 'Nurse, I feel like I'm going to die,' which response is most therapeutic?
- A. You are having a panic attack.
- B. You don't want the physician to see you this way.
- C. Everyone feels frightened in an emergency.
- D. I'll stay with you until you feel better.
Correct Answer: D
Rationale: Staying with the client provides reassurance and support, directly addressing their fear and promoting a sense of security.
Which technique is most therapeutic for helping clients with dementia remain oriented?
- A. Address all clients using their first name.
- B. Ask clients to identify their goals for the day.
- C. Assign clients to greet visitors each day.
- D. Post large calendars with the current date.
Correct Answer: D
Rationale: Large calendars provide a constant visual cue, aiding orientation to time in clients with dementia.
The client has been placed in restraints for violent behavior. Which statement best indicates the nurse’s understanding of the risk for client injury while being restrained?
- A. “Can you arrange to order the client’s favorite sandwich for his lunch?”
- B. “I need to make sure the restraints’ release mechanisms are working properly.”
- C. “I need someone to continuous monitor the client and relieve me for a few minutes.”
- D. “The client’s feet feel a little cool but they have a good pulse. I’ll get a pair of socks.”
Correct Answer: C
Rationale: Continuous monitoring (C) prevents injury during restraint. Nutrition (A) release mechanisms (B) and circulation checks (D) are secondary to constant observation.