Nokea
The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
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The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.
The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.
Fluoxetine hydrochloride is prescribed for a client with a diagnosis of depression. The nurse provides instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication?
- A. I should take the medication with my evening meal.
- B. I should take the medication at noon with an antacid.
- C. I should take the medication in the morning when I first arise.
- D. I should take the medication right before bedtime with a snack.
Correct Answer: C
Rationale: Fluoxetine hydrochloride is an antidepressant and is administered in the early morning without consideration of meals. The remaining options present either incorrect times or incorrect conditions to take this medication.
A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and should base the discussion on which information?
- A. Rest is an essential component of bone healing.
- B. Setting limits on a client's behavior is a mandated nursing role.
- C. Not keeping up with his job will increase the client's stress level.
- D. Involvement in his job will keep the client from becoming bored.
Correct Answer: A
Rationale: Rest is an essential component of bone healing, particularly after a hip fracture repair with a prosthetic implant. Engaging in work-related activities, such as planning a phone meeting, may interfere with the necessary rest and recovery process. Options 2, 3, and 4 do not prioritize the physiological need for rest and healing, which is critical at this stage of recovery.
A client who is experiencing suicidal thoughts shares with the nurse that, 'I was awake most of the night. It just doesn't seem worth it anymore. Why not just end it all?' Which response should the nurse make to best further assess the client?
- A. Did you sleep at all last night?
- B. Tell me what you mean by that.
- C. I know you have had a stressful night.
- D. I'm sure that your family is worried about you.
Correct Answer: B
Rationale: Option 2 allows the client the opportunity to tell the nurse more about what his or her current thoughts are. Option 1 changes the subject and may block communication. Although option 3 offers empathy to the client, it does not further assess the client. Option 4 is false reassurance and may block communication.