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A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.
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A cooling blanket is ordered for an adult client who has a temperature of 106°F. What nursing action is essential because the client has a cooling blanket?
- A. Keep a padded tongue blade at the bedside.
- B. Turn every two hours.
- C. Apply ice to the groin area.
- D. Cover with a sheet and blanket.
Correct Answer: B
Rationale: Turning every two hours prevents skin breakdown from prolonged cooling blanket contact. Tongue blades, ice, or heavy coverings are inappropriate.
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
- A. The client says, 'I will change the bag as soon as it gets full.'
- B. The client is observed irrigating the colostomy while sitting on the toilet.
- C. The client positions the irrigating solution container at shoulder level.
- D. The client places a chlorophyll tablet in the drainage bag.
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to
- A. achieve harmony
- B. maintain a balance of energy
- C. respect life
- D. restore yin and yang
Correct Answer: D
Rationale: For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.
A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client's medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours?
- A. Digoxin (Lanoxin)
- B. Diltiazem (Cardizem)
- C. Nitroglycerine ointment
- D. Metoprolol (Toprol XL)
Correct Answer: A
Rationale: Digoxin (Lanoxin). Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.