Nokea
A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
- A. What has your neighbor been doing that bothers you?'
- B. How long have you been hearing these terrible voices?'
- C. I won't let your neighbor visit, so you'll be safe.'
- D. What exactly are these terrible voices saying to you?'
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
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When using crutches, the client should be instructed to bear weight primarily on the:
- A. Axillae
- B. Elbows
- C. Upper arms
- D. Hands
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.
You are caring for a group of clients who are adversely affected with phobias. Which form of group therapy will you most likely employ to treat these clients?
- A. Cognitive psychotherapy
- B. Behavioral psychotherapy
- C. Cognitive behavioral psychotherapy
- D. Psychoanalysis
Correct Answer: C
Rationale: Cognitive behavioral psychotherapy (CBT) is the most effective treatment for phobias, as it combines cognitive restructuring with behavioral techniques like exposure therapy to address irrational fears.
The nurse judges that the parents of a newborn with imperforate anus know what a low defect is when they say that the rectum:
- A. Is below the abdominal rectus muscle
- B. Is above the abdominal rectus muscle
- C. Has descended through the puborectalis muscle
- D. Has ascended through the puborectalis muscle
Correct Answer: C
Rationale: A low defect in imperforate anus means the rectum has descended through the puborectalis muscle, indicating a less severe anomaly. Other options describe incorrect anatomical positions.
A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.