Nokea
If the client's pain is the result of a panic attack, which findings will the nurse most likely note during the physical assessment? Select all that apply.
- A. Tachycardia
- B. Hypotension
- C. Increased salivation
- D. Constricted pupils
- E. Sweating
- F. Unsteady gait
Correct Answer: A,E
Rationale: Panic attacks typically cause tachycardia and sweating due to sympathetic nervous system activation, reflecting acute anxiety.
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The nurses critique a chart entry that says, 'States, I feel unwanted." Appears to be confused.' Which statement best describes why this entry is unsatisfactory?"
- A. The nurse who made the entry failed to interpret the significance of feeling unwanted.
- B. The nurse who made the entry failed to indicate the importance of the client's statement.
- C. The nurse who made the entry failed to substantiate that the client made the quote.
- D. The nurse who made the entry failed to describe the evidence of the confused behavior.
Correct Answer: D
Rationale: Failing to describe specific behaviors supporting 'confused' makes the entry vague, reducing its clinical usefulness.
When debriefing the unit’s staff after the client’s catastrophic reaction the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?
- A. The client’s safety is at jeopardy if the staff is feeling threatened.
- B. An agitated staff will not be able to manage the situation as effectively.
- C. The client will sense the staff’s agitation and aggressive behavior will escalate.
- D. An agitated staff response is indicative of a need for additional crisis-control training.
Correct Answer: C
Rationale: Staff agitation escalates client aggression (C). Safety (A) management (B) and training (D) are secondary concerns.
The client receiving treatment for substance dependence has not been attending group therapy. Which response by the nurse to confront this behavior is best?
- A. “Why don’t you want to go to group therapy? Other users are there waiting for you to attend.”
- B. “Talking about personal issues with others can be difficult. Try talking to the therapist alone.”
- C. “Therapy is important to your treatment. You need to attend therapy if you want to get better.”
- D. “You say you want to get better but you are not actively participating in your treatment plan.”
Correct Answer: D
Rationale: Confronting nonattendance nonjudgmentally (D) addresses denial. “Why” questions (A) suggesting alternatives (B) or threats (C) are less effective.
Which nursing intervention is most beneficial for the client's spouse at this time?
- A. Suggesting that the spouse make an appointment for a physical examination
- B. Discussing modifying the amount of time the spouse devotes to care-giving
- C. Reminding the spouse of the scheduled times for visiting clients on the unit
- D. Explaining that many staff are available to care for the client
Correct Answer: B
Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.
While caring for a client who is withdrawing from alcohol, the nurse must assess for what additional complication?
- A. Hypothermia
- B. Seizures
- C. Ascites
- D. Jaundice
Correct Answer: B
Rationale: Seizures are a serious complication of alcohol withdrawal, requiring vigilant monitoring due to their potential for harm.