Nokea
A client suffering from visual hallucinations calls the nurse to her room and says, 'You need to hurry up and kill all these bugs on the wall before they get on me.' Which response by the nurse is most appropriate?
- A. Why don't you lay down and take a nap?
- B. I don't see them. Can you show me where they are?
- C. I will call maintenance and have them come take care of this right away.
- D. I know the bugs seem real to you, but I don't see anything on the walls.
Correct Answer: D
Rationale: This response acknowledges the client's perception without reinforcing the hallucination, promoting trust and reality orientation.
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A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?
- A. Staying with the client
- B. Distracting the client with television
- C. Interpreting the arterial blood gas report
- D. Encouraging the client to cough and breathe deeply
Correct Answer: A
Rationale: Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress.
The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which should the nurse assess to yield the best information about this area of functioning?
- A. Judgment
- B. Emotions
- C. Consciousness
- D. Eye movements
Correct Answer: B
Rationale: Feelings and emotions are part of the role of the limbic system. Eye movements are under the control of cranial nerves III, IV, and VI. The level of consciousness is controlled by the reticular activating system. Insight, judgment, and planning are part of the function of the frontal lobe.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
- A. monitor the airway and be prepared to provide suction if needed
- B. continuously observe vital signs and cardiac function on the monitor
- C. provide support and safe positioning to the client's arms and legs during the seizure
- D. record the type, frequency, duration, and amount of movement induced by the seizure
Correct Answer: A
Rationale: Airway management is the priority during ECT due to the risk of aspiration or respiratory compromise during induced seizures.
A client diagnosed with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse should make which interpretation about this behavior?
- A. The client is depressed.
- B. The client is noncompliant.
- C. The client has intractable pain.
- D. The client is unable to tolerate activity.
Correct Answer: A
Rationale: Depression is a common problem related to clients who have long-term and debilitating illnesses. None of the remaining options are related to the symptoms present in the question and therefore are not appropriate interpretations.