Nokea
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
- A. Ineffective community coping
- B. Disturbed sensory perception
- C. Self-care deficit
- D. Acute confusion
Correct Answer: D
Rationale: Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue. While self-care deficit could be a concern, it is not the priority when the client is disoriented.
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A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?
- A. Ignore the nonverbal behavior and focus on the client's verbal messages
- B. Integrate the verbal and nonverbal messages and interpret them as one
- C. Ask the client's spouse to interpret the discrepancy
- D. Pay close attention and document the nonverbal messages
Correct Answer: D
Rationale: Paying close attention and documenting nonverbal messages gathers comprehensive data for further exploration. Ignoring nonverbal cues misses important information. Integrating messages prematurely may misinterpret the discrepancy. Asking the spouse to interpret is inappropriate and may not be accurate.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?
- A. Share personal values to put the client at ease
- B. Ask questions in a vague, non-specific format
- C. Begin with questions that are less sensitive in nature
- D. Get the most difficult questions over with first
Correct Answer: C
Rationale: Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation. Sharing personal values may blur professional boundaries. Vague questions may not yield accurate information. Starting with difficult questions may overwhelm the client and hinder trust.
An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?
- A. Cares for an older parent and her children
- B. Anxious to leave for personal appointments
- C. Takes naps in her car during lunch hour
- D. Works an average of 60 hours per week
Correct Answer: A
Rationale: Caring for an older parent and children simultaneously indicates significant caregiver role strain due to increased responsibilities. Anxiety, napping, and long work hours suggest stress but are less specific to caregiving demands.
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Administer the prescribed anticholinergic benztropine for dystonia
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms
- C. Direct the client to occupational therapy to distract him from somatic complaints
- D. Medicate the client with the prescribed antipsychotic thioridazine
Correct Answer: A
Rationale: The client's laterally contracted position and perception of contortion suggest acute dystonia, a side effect of risperidone. Benztropine, an anticholinergic, alleviates dystonia. Hot packs, occupational therapy, or thioridazine do not address this acute reaction.