Nokea
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. I understand you're depressed, but killing yourself is not a reasonable option.'
- B. We need to discuss this further, but right now let's complete these forms.'
- C. Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.'
- D. This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.'
Correct Answer: D
Rationale: To the client, suicide may be a reasonable action and the only one he can cope with at this time. This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
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The nurse is explaining to an adult client with an ulcer diagnosis about the drug esomeprazole (Nexium). Which side effect(s) will the nurse want to include in the discussion?
- A. Headache
- B. Diarrhea
- C. Flushing
- D. Dizziness
- E. Nausea
Correct Answer: A, B, D, E
Rationale: Esomeprazole side effects include headache (A), diarrhea (B), dizziness (D), and nausea (E). Flushing (C) is not a common side effect.
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
- A. He should monitor his sputum, stools, and urine for signs of bleeding.
- B. His daily diet should include a large amount of fluid.
- C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.
- D. He should not worry about having children because this disease is passed on only by female carriers.
Correct Answer: B
Rationale: Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this client should receive genetic counseling prior to having children.
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
- A. Always allow the most vocal person to state the problem first.
- B. Encourage the mother to speak for the children.
- C. Interpret immediately what seems to be going on within the family.
- D. Allow family members to assume the seats as they choose.
Correct Answer: D
Rationale: Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
- A. Deviation of the trachea to the unaffected side
- B. Muffled heart sounds on the affected side
- C. Increased breath sounds on the affected side
- D. Decreased chest movement on the affected side
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.
The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction is most important?
- A. Low potassium
- B. Low calcium
- C. Low magnesium
- D. Low iron
Correct Answer: A
Rationale: Chronic kidney disease impairs potassium excretion, risking hyperkalemia, which can cause arrhythmias. Low potassium diets are critical. Calcium, magnesium, and iron are less commonly restricted.