Nokea
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
- A. You shouldn't let yourself get so upset
- B. Don't worry about them. They don't mean any harm
- C. Look. They seem to be having fun
- D. They're laughing at a joke John told. They aren't laughing at you
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.
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Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
The nurse is teaching a client with hypertension about dietary modifications. Which statement by the client indicates understanding of the teaching?
- A. I should increase my intake of processed foods.'
- B. I will limit my sodium intake to 2,300 mg per day.'
- C. I can drink coffee as much as I want.'
- D. I should avoid fruits like bananas.'
Correct Answer: B
Rationale: Limiting sodium to 2,300 mg per day or less helps manage hypertension by reducing fluid retention and blood pressure.
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.
A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
- A. Pain
- B. Urticaria
- C. Headache
- D. Skin redness
Correct Answer: B
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.