Nokea
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Teach the client strategies to control her obsessive-compulsive behavior.
- C. Ask the client to explain why she is keeping a detailed record of her nursing care.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express feelings regarding the upcoming procedure addresses potential anxiety driving the behavior, offering a therapeutic approach.
You may also like to solve these questions
The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?
- A. Allow the adolescents to sit wherever they wish as long as they participate.
- B. Suggest that they all sit together to increase interaction.
- C. Ask the adolescent sitting on the couch to join the group at the table.
- D. Determine which adolescents would like to participate in the discussion.
Correct Answer: C
Rationale: Asking the adolescent on the couch to join the table promotes inclusivity and equal participation, enhancing group interaction.
After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?
- A. Instruct the client to reduce the volume of his voice.
- B. Accompany the client to a quiet area of the unit.
- C. Encourage the client to attend a support group.
- D. Administer a PRN sedative by injection.
Correct Answer: B
Rationale: Accompanying the client to a quiet area provides a calming environment, helping to deescalate the client's agitated state.
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?
- A. Ask the client to describe the history of the injuries.
- B. Invite a colleague to document during the interview.
- C. Close the examination room door for privacy.
- D. Request hospital security to come to the department.
Correct Answer: C
Rationale: Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history, facilitating open communication.
A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant amitriptyline that he uses to help him sleep. After reviewing the assessment findings with the healthcare provider, a serum creatinine is obtained. Which information supports the reason for this laboratory test?
- A. Creatinine can measure how the body is metabolizing the lithium in the liver.
- B. The effects of amitriptyline can promote and potentiate the risk of lithium toxicity.
- C. The combination of lithium and amitriptyline may need to be changed if creatinine is high.
- D. Lithium is excreted by the kidneys, and creatinine is related to kidney functioning.
Correct Answer: D
Rationale: Lithium is excreted by the kidneys, and monitoring creatinine levels assesses renal function, guiding dosage to prevent toxicity.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
- A. Determine the client's reason for attempting suicide.
- B. Obtain the client's serum hydrocodone/acetaminophen level.
- C. Encourage the client to increase fluid intake.
- D. Observe the client for further narcotic effects.
Correct Answer: A
Rationale: Determining the client's reason for attempting suicide is the highest priority to understand underlying issues and plan appropriate interventions to prevent recurrence.