Nokea
Which assessment finding is most atypical of a 65-year-old client?
- A. Making errors in copying a line drawing
- B. Forgetting the names of longstanding neighbors
- C. Reading information slowly
- D. Naming only two of the last three presidents
Correct Answer: A
Rationale: Errors in copying a drawing suggest visuospatial deficits, less common in typical aging and more indicative of neurological issues.
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When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.
The older disheveled client is admitted to the ED with hypertension severe dehydration and malnourishment. During the admission interview the daughter notes that she and her husband who is temporarily out of work have been living with the client. Which nursing action is most important?
- A. Report the suspected elder abuse to Adult Health Protective Services.
- B. Ask additional questions of the client in private without the family present.
- C. Ask the daughter whether her father has been eating and taking his medication.
- D. Call the resource hotline to ask whether abuse and neglect should be considered.
Correct Answer: B
Rationale: Private questioning (B) elicits abuse/neglect details. Reporting (A) needs more evidence asking the daughter (C) is less direct and calling a hotline (D) is secondary.
The nurse is educating the client on the methadone prescribed for replacement therapy while in an outpatient treatment program for heroin addicts. The client asks how taking a pill is going to help the client stay substance-free. Which statement is the nurse’s best reply?
- A. “The methadone will give you the same high so you won’t want heroin anymore.”
- B. “The methadone will cause you to become very sick if you take heroin at the same time”
- C. “The methadone ‘replaces’ heroin in your body so you will have fewer cravings for heroin.”
- D. “The methadone causes sedation; you’ll sleep better so you can participate in your treatment.”
Correct Answer: C
Rationale: Methadone displaces heroin reducing cravings (C). It doesn’t produce a high (A) cause sickness (B) or sedate (D).
The spouse of the client who is currently in inpatient treatment for substance abuse tells the nurse “We’ve done this so many times. I don’t think my spouse is ever going to change. Do you think it’s time for me to get a divorce?” Which response by the nurse is most helpful?
- A. “You don’t think your spouse is ever going to change?”
- B. “Sounds like you’re feeling discouraged in your marriage.”
- C. “Your spouse will likely continue to use and need treatment again.”
- D. “That’s your decision; I can’t tell you whether you should get a divorce.”
Correct Answer: B
Rationale: Validating discouragement (B) encourages exploration. Restatement (A) is less effective predicting relapse (C) is opinionated and dismissing (D) closes communication.
The nurse manager concerned about the potential for staff harm on a behavioral health unit is assessing the unit’s milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence?
- A. Two clients have a history of spousal abuse.
- B. Several clients have lost smoking privileges.
- C. The unit is currently at less than full client capacity.
- D. The nurse from a medical unit is assigned to work on the unit.
Correct Answer: D
Rationale: Staff inexperience (D) predicts violence. Client history (A) and privileges (B) are client-focused and low capacity (C) reduces not increases risk.