Nokea
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.
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The client who recently emigrated from Iran is on the mental health unit and has been placed in seclusion. The nurse assesses that the client is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity?
- A. Gives the client a thumbs-up gesture
- B. Avoids looking at the clock or a watch
- C. Has the NA bring the client a cup of tea
- D. Offers to bring the client the book of Quran
Correct Answer: A
Rationale: A thumbs-up (A) is offensive in Iranian culture akin to a vulgar gesture. Avoiding clocks (B) offering tea (C) and providing the Quran (D) are culturally appropriate.
Which response by the nurse is best in this situation?
- A. That is something to discuss with your physician.
- B. It sounds like you're feeling discouraged.
- C. But you're about your lack of progress.
- D. You need to practice a little more patience.
Correct Answer: B
Rationale: Acknowledging discouragement validates the client's feelings, fostering therapeutic communication and emotional support.
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.
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.
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.