Nokea
A client with antisocial personality disorder tells the nurse, 'I punched the guy out because he deserved it and then the cops arrested me.' Which of the following responses would be most helpful to the client?
- A. It's wrong to punch others.'
- B. If you punch people out, you'll get into trouble.'
- C. I wouldn't do that again if I were you.'
- D. Don't ever do that again; you're an adult.'
Correct Answer: B
Rationale: Explaining consequences (legal trouble) helps the client understand the impact of their actions, aligning with therapeutic communication for antisocial personality disorder.
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A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?
- A. I will implement my exercise program as soon as I get home.'
- B. I will be careful not to cross my legs.'
- C. I will need an elevated toilet seat.'
- D. I can't wait to take a tub bath when I get home.'
Correct Answer: D
Rationale: Tub baths are contraindicated post-hip replacement due to the risk of hip flexion beyond 90 degrees, indicating a need for further teaching.
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
- A. Pulmonary embolism
- B. Vitamin K deficiency
- C. Factor VIII deficiency
- D. Disseminated intravascular coagulopathy (DIC)
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
- A. Threatening others and throwing furniture is not allowed.'
- B. You have been restrained until you can manage your behavior.'
- C. Since you have been here before, you know what the rules are.'
- D. We are only doing this for your own good, so calm down.'
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
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.