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A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?
- A. Just wait here and I will notify security.
- B. I'm going to speak with the physician about getting some medication that may help you.
- C. Why is your roommate trying to kill you?
- D. Have you called the police to report this?
Correct Answer: C
Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.
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A client is discussing his personal feelings of self-esteem and self-concept with a nurse. Which of the following questions is most appropriate for assessing the client's personal identity?
- A. What is your educational background?
- B. Are your parents still living?
- C. What do you like about your life right now?
- D. Where do you see yourself in 10 years?
Correct Answer: C
Rationale: When assessing a client's personal identity, it is essential for the nurse to inquire about aspects related to the client's self-perception and self-worth. Asking about what the client likes about his current life helps to explore his positive self-perceptions and areas of contentment. This question encourages the client to reflect on his present circumstances and identify aspects that contribute to his sense of personal identity. Choices A, B, and D are not as relevant for assessing personal identity as they focus on educational background, parental status, and future aspirations, respectively, rather than directly addressing the client's current self-perception and identity.
Which of the following actions is most appropriate when working with a client who is extremely angry?
- A. Place a light hand on the client's shoulder to convey understanding
- B. Maintain close proximity to build trust
- C. Temporarily change the subject if the client's behavior is escalating
- D. Close the door to the room to ensure privacy
Correct Answer: C
Rationale: When dealing with an angry client, it is crucial to employ techniques that can help de-escalate the situation or ensure safety while providing care. If the client's behavior is escalating or they are fixating on a particular topic that is fueling their anger, it is advisable to temporarily change the subject. This technique can serve as a distraction from the initial trigger, allowing the client to refocus their thoughts and emotions. Placing a hand on the client's shoulder may not be well-received as physical touch can escalate the situation. Maintaining close proximity might be perceived as confrontational rather than building trust. Closing the door for privacy is important but may not directly address the client's anger or help in de-escalation.
Which of the following individuals is at the highest risk of experiencing intimate partner violence?
- A. A 36-year-old woman who is recently divorced
- B. A 22-year-old man who is unemployed but living with friends
- C. A 20-year-old woman who grew up with a psychologically abusive father
- D. A 40-year-old man diagnosed with schizophrenia
Correct Answer: C
Rationale: Intimate partner violence is a serious issue encompassing physical, psychological, or sexual abuse within an intimate relationship. Individuals who have experienced psychological abuse in their upbringing are at a higher risk of becoming victims themselves due to the normalization of abusive behaviors. While factors such as age, mental health conditions, and social support can contribute to vulnerability, growing up in an abusive environment can significantly heighten the risk of intimate partner violence. The other options, such as recent divorce (A), unemployment (B), and schizophrenia diagnosis (D), do not directly correlate with the same level of increased risk associated with a history of psychological abuse.
A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
- A. Administer anti-anxiety medications as prescribed by the healthcare provider
- B. Engage in a conversation with the client regarding methods to enhance rest and sleep
- C. Escort the client to a private room and stay with them
- D. Review the client's medical history to determine previous treatment for these issues
Correct Answer: C
Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct Answer: C
Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option D) as the catheter could be inserted easily.