Nokea
A client who voluntarily admitted herself to the mental health hospital adamantly demands to be discharged immediately. What is the most appropriate response by the nurse?
- A. We hate to see you go, but that is your right. I'll get the forms for you so you can go.'
- B. I'm sorry, but your lawyer or family must request such forms when you are hospitalized.'
- C. I will get the forms, but your psychiatrist will need to see you before you leave.'
- D. Are you sure we can't convince you to stay here in a few days? You'll return to a full valid and there are several issues we need to address.'
Correct Answer: C
Rationale: For voluntary admissions, clients can request discharge, but a psychiatric evaluation is typically required to ensure safety. This response ensures protocol is followed while addressing the client's request.
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Your client has a tube feeding. Which of the following commonly occurring complications of tube feedings can you prevent with the preventive measure that is coupled with it?
- A. Constipation: The provision of a high fiber diet
- B. Urinary pH changes: Encouraging ample oral fluid intake
- C. Aspiration: Maintaining the client in at least a 30 degree angle
- D. Aspiration: Maintaining the client in at least a 90 degree angle
Correct Answer: C
Rationale: Maintaining a 30-45 degree angle during tube feedings reduces the risk of aspiration by preventing reflux of gastric contents.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Serum sodium.
- C. Blood urea nitrogen.
- D. Blood glucose.
Correct Answer: D
Rationale: TPN contains high glucose concentrations, requiring close monitoring of blood glucose to prevent hyperglycemia.
The nurse is caring for a client with a history of glaucoma who is prescribed timolol (Timoptic) eye drops. The nurse should instruct the client to report which of the following side effects?
- A. Blurred vision.
- B. Bradycardia.
- C. Eye redness.
- D. Dry eyes.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, which should be reported immediately.
A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.
The nurse is teaching a client with a new diagnosis of celiac disease about dietary management. Which of the following foods should the client avoid?
- A. Rice.
- B. Wheat.
- C. Corn.
- D. Potatoes.
Correct Answer: B
Rationale: Wheat contains gluten, which must be avoided in celiac disease.