Nokea
A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?
- A. Tell the client that their delusions are not real
- B. Encourage the client to explore the meaning behind their delusions
- C. Focus on the client's feelings rather than the delusions
- D. Challenge the client's delusions directly
Correct Answer: C
Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.
You may also like to solve these questions
A client has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Hemoglobin
Correct Answer: A
Rationale: When a client is prescribed furosemide, monitoring potassium levels is crucial due to the drug's potential to cause hypokalemia. Furosemide is a loop diuretic that promotes potassium excretion in the urine, leading to a risk of low potassium levels. Monitoring potassium levels helps in detecting and preventing hypokalemia, which can result in adverse effects like cardiac dysrhythmias. Sodium, calcium, and hemoglobin levels are usually not directly affected by furosemide, making them less pertinent for monitoring in this specific scenario.
A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?
- A. Nuchal rigidity.
- B. Flaccid paralysis.
- C. Bradycardia.
- D. Hypothermia.
Correct Answer: A
Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.
A nurse is reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. Blood pressure 130/80 mm Hg
- C. Weight gain of 2.2 kg (5 lb) in 1 week
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.
A nurse is caring for a client who is receiving furosemide. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?
- A. Serum sodium.
- B. Serum glucose.
- C. Serum potassium.
- D. Serum calcium.
Correct Answer: C
Rationale: The correct answer is C: Serum potassium. Furosemide is a potassium-wasting diuretic, meaning it can lead to potassium loss in the body. Monitoring serum potassium levels is crucial to evaluate the effectiveness of furosemide and prevent hypokalemia. Options A, B, and D are incorrect because furosemide does not directly affect sodium, glucose, or calcium levels in the same way it impacts potassium levels.
A nurse is preparing to administer packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Prime the IV tubing with dextrose 5% in water
- B. Ensure the client's consent is on file
- C. Check the client's identification using two identifiers
- D. Administer the blood through a 22-gauge catheter
Correct Answer: C
Rationale: The correct first action for the nurse to take when preparing to administer packed RBCs is to check the client's identification using two identifiers. This step is crucial to ensure that the right blood is given to the right client, preventing any transfusion errors. Priming the IV tubing with dextrose 5% in water and administering the blood through a 22-gauge catheter are important steps but should come after confirming the client's identity. Ensuring the client's consent is on file is also important but is not the immediate priority when preparing to administer packed RBCs.