Nokea
A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is
- A. Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK.'
- B. The food has been prepared in our kitchen and is not poisoned.'
- C. Let's see if your partner could bring food from home.'
- D. If you don't eat, I will have to suggest for you to be tube fed.'
Correct Answer: C
Rationale: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise.
You may also like to solve these questions
The nurse in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the charge nurse.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.
The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor?
- A. Blood pressure
- B. Hematuria
- C. Peripheral edema
- D. Serum lipid levels
Correct Answer: A
Rationale: Hypertension is a priority in glomerulonephritis due to fluid retention, risking complications. Hematuria , edema , and lipids are monitored but less urgent.
An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse?
- A. I understand your desire to leave, but it would be very risky.
- B. I will ask the palliative care nurse to talk with you to help clarify your care goals.
- C. I will let the HCP know that you want to be discharged and do everything I can to make it happen.
- D. Tell me more about your need to leave the hospital.
Correct Answer: D
Rationale: Exploring the client's reasons respects autonomy and facilitates understanding. Warning about risks may dismiss feelings, referring to palliative care is premature, and promising discharge bypasses collaboration.
A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:
- A. Cause diarrhea
- B. Change the color of her urine
- C. Cause mental confusion
- D. Cause changes in taste
Correct Answer: C
Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.