Nokea
Which action is most appropriate for the nurse to take first?
- A. Remind the client that clothes are required in public.
- B. Instruct the client to put clothes on again.
- C. Explain to the residents that the client is not of sound mind.
- D. Take the client to a vacant room nearby.
Correct Answer: D
Rationale: Taking the client to a private room ensures dignity and safety, addressing the immediate need without public confrontation.
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Which of the following identified assessment criteria is the highest priority for this client?
- A. The number of characteristics of the client's bowel movements
- B. How much the client knows about colostomy care
- C. Which coping mechanisms the client uses for handling stress
- D. The types of relationships the client has with peers
Correct Answer: A
Rationale: Monitoring bowel movements is critical in ulcerative colitis to assess disease activity and guide treatment, prioritizing physical health.
The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?
- A. Call the mental health unit to arrange for inpatient treatment.
- B. Give medications to reverse the effects of the hallucinogenic drug.
- C. Stay with the client to protect the client from self-harm until relieved.
- D. Call hospital security so security staff is present to protect staff from injury.
Correct Answer: C
Rationale: Staying with the client (C) prevents self-harm due to altered perception. Inpatient arrangements (A) reversal drugs (B unavailable) and security (D) are secondary.
Which concept is most important for the nurse to convey to a client during a panic attack?
- A. The client is safe.
- B. The client is believed.
- C. The client is cared for.
- D. The client is accepted.
Correct Answer: A
Rationale: Reassuring safety addresses the client's fear, a core component of panic attacks, helping to de-escalate anxiety.
Which statement made by the client diagnosed with human immunodeficiency virus (HIV) would the nurse interpret as the most serious indication of an increased risk for suicide?
- A. I have been having recurring dreams about dying.
- B. How many people have died from HIV?
- C. Will I be alert when I'm near death?
- D. Everyone would be better off without me.
Correct Answer: D
Rationale: Expressing that others would be better off without them suggests feelings of worthlessness and hopelessness, strong indicators of suicidal ideation.
When resuscitation efforts are unsuccessful, which nursing action is most appropriate?
- A. Ask the parents for permission to perform an autopsy.
- B. Ask about the possibility of harvesting the infant's organs for transplantation.
- C. Check on the parents' choice for the funeral arrangements.
- D. Take the parents to a room where they can be with the baby.
Correct Answer: D
Rationale: Allowing parents to spend time with their deceased infant supports grieving and closure, prioritizing their emotional needs immediately after the loss.