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A manic client is admitted to an inpatient psychiatric center. He is hyperactive, talking quickly, acting aggressively, and pacing. The nursing staff should
- A. outline realistic expectations for the client's behavior.
- B. ignore the client's behavior.
- C. allow the client to eat lunch with other clients to observe the interaction.
- D. assign an RN to stay with the client at all times.
Correct Answer: D
Rationale: A manic client’s behavior requires close supervision for safety. Assigning an RN to stay with the client ensures monitoring and intervention as needed.
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A client is being treated for irritable bowel syndrome (IBS). The nurse knows that the involvement of nursing, pharmacy, gastroenterology, and nutritional services is an example of which of the following approaches?
- A. continuity of care
- B. multidisciplinary
- C. managed care
- D. case management
Correct Answer: B
Rationale: A multidisciplinary approach involves multiple specialties (nursing, pharmacy, gastroenterology, nutrition) collaborating to manage IBS.
A med-surg nurse is floating to the post-op floor for a few days. The float nurse sees one of the regular post-op nurses taking medication from the med cart and ingesting several pills. The float nurse should immediately
- A. inform the state board of nursing.
- B. inform the nursing supervisor who works on the post-op floor.
- C. report the nurse to human resources.
- D. confront the post-op nurse about stealing and abusing medications.
Correct Answer: B
Rationale: Reporting to the nursing supervisor ensures prompt investigation and intervention for suspected medication diversion, maintaining patient safety.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A. Her contractions are 2 minutes apart.
- B. She has back pain and a bloody discharge.
- C. She experiences abdominal pain and frequent urination.
- D. Her contractions are 5 minutes apart.
Correct Answer: D
Rationale: Contractions 5 minutes apart indicate the onset of active labor, prompting further evaluation.
The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture uses:
- A. Pressure from the fingers and hands to stimulate the energy points in the body
- B. Oils extracted from plants and herbs
- C. Needles to stimulate certain points on the body to treat pain
- D. Manipulation of the skeletal muscles to relieve stress and pain
Correct Answer: C
Rationale: Acupuncture uses needles, which pose an infection risk in immunocompromised AIDS patients, requiring further discussion.
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.