Nokea
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
- A. Halloween is getting close, isn't it.'
- B. Do you have a black cat?'
- C. What's the connection between cats, hats, and time?'
- D. Time certainly does go faster these days.'
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.
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The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?
- A. Vital signs
- B. Motor function
- C. Sensory function
- D. Level of consciousness
Correct Answer: D
Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats 'lots of rice.' To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
- A. Beans.
- B. Soy milk.
- C. Yogurt.
- D. Corn.
Correct Answer: A
Rationale: Combining rice with beans provides a complete protein, meeting the increased protein needs during pregnancy.
The nurse is working in a newborn nursery and caring for several neonates. Precautions that should be taken to prevent an infant abduction include which of the following?
- A. Notifying the hospital's security staff about anyone who appears unusual.
- B. Taking several neonates to their mothers at the same time.
- C. Placing the infant near the doorway of the mother's room.
- D. Contacting the hospital's security staff if an exit alarm is triggered.
Correct Answer: A,D
Rationale: Notifying security about suspicious individuals and responding to exit alarms are key to preventing abductions. Taking multiple neonates or placing them near doorways increases risk.
The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for:
- A. Anesthesia below the level of the injury.
- B. Tingling in the fingers.
- C. Pain below the site of the injury.
- D. Loss of position and vibratory sense.
Correct Answer: A,D
Rationale: Spinal cord injury often causes anesthesia (loss of sensation) and loss of position/vibratory sense below the injury level. Tingling or pain below the injury is less likely due to disrupted nerve pathways.
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.