Nokea
A newly admitted client is exhibiting signs of severe anxiety. She is pacing back and forth and has difficulty concentrating on the nurse's questions. What nursing action is most appropriate at this time?
- A. Tell the client to sit down and get control of herself
- B. Leave the room until she regains control
- C. Whisper to her that everything will be all right
- D. Attend to her behavior and direct her to a quiet area
Correct Answer: D
Rationale: Directing the client to a quiet area reduces stimuli, helping manage severe anxiety. Commands, leaving, or whispering are ineffective or dismissive.
You may also like to solve these questions
Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess and document skin turgor and color changes
- B. Test stool for occult blood and urine for glucose and report results
- C. Suggest foods high in iron and those easily consumed
- D. Report mental status changes and the degree of mental clarity
Correct Answer: B
Rationale: Test stool for occult blood and urine for glucose and report results. The UAP can do standard, unchanging procedures that require no decision making.
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication
A client on chemotherapy has a WBC count of 1,200/mm^3. Which of the following nursing actions should the nurse take FIRST?
- A. Check temperature q 4 h.
- B. Monitor urine output.
- C. Assess for bleeding gums.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: A WBC count of 1,200/mm^3 indicates severe neutropenia, increasing infection risk. Checking temperature every 4 hours detects fever early, a priority. Options B, C, and D are secondary: urine output is unrelated, bleeding gums suggest thrombocytopenia, and blood cultures require fever.
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
The triage nurse for a women's health center receives a phone call from each of the following women.
Which woman should be directed to come to the health care facility IMMEDIATELY?
- A. A multipara woman who is four weeks pregnant and reporting unilateral, dull abdominal pain.
- B. A primipara woman who is seven weeks pregnant and reporting an increase in whitish vaginal secretions.
- C. A primigravida woman who is five weeks gestation and is having vaginal spotting and some cramping.
- D. A multigravida woman who is six weeks pregnant and reporting frank, red vaginal bleeding with moderate cramps.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-needs to be evaluated for an ectopic pregnancy (2) expect during first trimester of pregnancy (3) symptomatic of threatened abortion; instruct to decrease activity (4) symptoms of spontaneous abortion; instruct client to save and count pads