Nokea
A client with schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. A suitable activity for a client with schizophrenia who is experiencing auditory hallucinations is:
- A. Watching a movie with other clients
- B. Working on a large-piece puzzle
- C. Playing a game of solitaire
- D. Taking a walk with the nurse
Correct Answer: D
Rationale: Taking a walk with the nurse provides distraction and support, reducing focus on hallucinations. Group activities or solitary tasks (B, C) may be overwhelming or less therapeutic.
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The nurse is attending a workshop about caring for persons infected with hepatitis. Which characteristic is most appropriate when defining the incidence rate of hepatitis?
- A. The number of persons in a population who develop hepatitis B during a specific period of time
- B. The total number of persons in a population who have hepatitis B at a particular time
- C. The percentage of deaths resulting from hepatitis B during a specific time
- D. The occurrence of hepatitis B in the population at a particular time
Correct Answer: A
Rationale: The number of persons in a population who develop hepatitis B during a specific period of time. This is the correct definition of incidence of the disease.
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
- A. Periorbital edema, absent light reflex and translucent tympanic membrane
- B. Irritability, rhinorrhea, and bulging tympanic membrane
- C. Diarrhea, fever, and reddened tympanic membrane
- D. Vomiting, pulling at ears and pearly white tympanic membrane
Correct Answer: B
Rationale: Irritability, rhinorrhea, and bulging tympanic membrane. These findings are characteristic of otitis media, indicating infection and inflammation of the middle ear.
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
- A. asking whether another individual wants to be her support person
- B. assuring her that the nursing triage group will be with her at all times
- C. telling her you will try to locate her family
- D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control
Correct Answer: A
Rationale: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her.
A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:
- A. Projection
- B. Displacement
- C. Undoing
- D. Compensation
Correct Answer: B
Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.