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When a new member to the group tells the nursing leader about sensing the presence of the dead spouse in the home, which nursing intervention is most appropriate?
- A. Recommending more professional counseling
- B. Assuring the client that it is wishful thinking
- C. Listening quietly and acknowledging the client's feelings
- D. Encouraging the client to stay with relatives
Correct Answer: C
Rationale: Listening and acknowledging feelings validates the client's experience, supporting grief processing in a therapeutic manner.
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The nurse educator is presenting a program on drug abuse to new nurses on the mental health unit. When explaining cocaine abuse which street names for cocaine should the nurse include in the discussion?
- A. Weed chaw fags
- B. Toot snow crack
- C. Uppers dexies crystal
- D. Blue silk cloud 9 white knight
Correct Answer: B
Rationale: Toot snow crack (B) are cocaine street names. Weed chaw fags (A) are nicotine uppers dexies crystal (C) are amphetamines blue silk cloud 9 white knight (D) are synthetics.
When the anxious client summons the nurse and reports feeling weak and dizzy, which nursing action is most appropriate at this time?
- A. Helping the client to relax
- B. Giving the client something to eat
- C. Administering oxygen by cannula
- D. Taking the client's vital signs
Correct Answer: D
Rationale: Taking vital signs assesses for physiological causes of weakness and dizziness, ensuring appropriate intervention for the anxious client.
The client is being admitted to the ICU with drug overdose that resulted in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and is kicking shoving throwing items in the room and threatening staff. The charge nurse calls a behavioral situation code and 4-point restraints are applied by the team. Which intervention is most important for the nurse to implement next?
- A. Have staff members who were harmed complete an incident report.
- B. Contact the health care provider to obtain an order for restraint use.
- C. Document the client’s behavior and action taken in the nurse’s notes.
- D. Check that the client’s wrist restraints are tightly secured to the HOB.
Correct Answer: B
Rationale: A physician or licensed independent practitioner must prescribe restraints and assess the client within 1 hour of restraint placement for client and staff safety. Incident reports (A) follow treatment documentation (C) follows HCP contact and securing restraints to the HOB (D) risks circulation impairment.
Which of the following verbal communication methods is best to use with a client with dementia?
- A. Speak loudly to get the client's attention.
- B. Use short sentences when speaking to the client.
- C. Use written forms of communication.
- D. Allow the client to listen to news programs.
Correct Answer: B
Rationale: Short sentences are easier for dementia clients to process, enhancing comprehension and reducing frustration.
The client with Alzheimer’s disease becomes increasingly agitated and states “I must go and clean out the barn!” Which nursing response is most therapeutic?
- A. “What makes you think that the barn needs to be cleaned?”
- B. “So you’ve cleaned a barn. Tell me did you live on a farm?”
- C. “It’s awfully hot today; maybe you should wait until tomorrow.”
- D. “There are no barns around here. Would you like something to eat?”
Correct Answer: B
Rationale: Redirecting to memories (B) calms agitation without confrontation. Asking why (A) or stating facts (D) may escalate and delaying (C) blocks communication.