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A client in the long-term care facility is confused and repeatedly asks the nurse for help finding the assigned room. Which response by the nurse is appropriate?
- A. Here is a map of the facility, including the room numbers.
- B. I think you can find your room if you just concentrate.
- C. Your room is on the first floor by the elevator doors.
- D. You didn't have any trouble finding your room yesterday.
Correct Answer: C
Rationale: Providing a clear, specific direction (room location by the elevator) helps orient the confused client without frustration. Maps are too complex, urging concentration is unhelpful, and referencing past ability may cause distress.
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The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
The nurse is planning care for a client with an intrauterine fetal demise. Which are appropriate goals for this client?
- A. The woman's grieving process will be limited to 6 months.
- B. The woman and her family will discuss plans for going home without the infant.
- C. The woman and her family will express their grief about the loss of their desired infant.
- D. The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.
- E. The woman and her family will contact their pastor or grief counselor for support after discharge.
Correct Answer: B,C,E
Rationale: It is important for the nurse to assess whether the client is undergoing the normal grieving process. Options 2, 3, and 5 are appropriate goals. Signs that are causes for concern and that are not part of the normal grieving process include thoughts of worthlessness and suicide and limiting the grieving process to a short amount of time.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
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.
The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?
- A. Support in maintaining a sense of control
- B. Less pain and anxiety than with a normal labor
- C. A sense of satisfaction regarding her quick labor
- D. Fewer fears regarding the effect of labor on the newborn infant
Correct Answer: A
Rationale: The client experiencing a precipitous labor may have more difficulty maintaining control because of the abrupt onset and quick progression of the labor. This may be very different from previous labor experiences; therefore, the client needs support from the nurse to understand and adapt to the rapid progression. The contractions often increase in intensity very quickly, which adds to the client's pain, anxiety, and lack of control. The client may also have an increased amount of concern about the effect of the labor on the newborn infant. A lack of control over the situation in combination with increased pain and anxiety can result in a decreased level of satisfaction with the labor and delivery experience.