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The client states that she slipped on some water outside of the shower.
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
- A. Notify the client's provider.
- B. Measure the client's vital signs.
- C. Document the fall in the client's medical record.
- D. Complete an incident report.
Correct Answer: B
Rationale: Measuring vital signs assesses for immediate injury, the priority action.
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A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
The client is visibly agitated and talking loudly in a group therapy session.
A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?
- A. Place the client in seclusion.
- B. Assist the client with understanding their needs.
- C. Ask the client to identify what made them upset.
- D. Administer lorazepam IM.
Correct Answer: C
Rationale: Identifying the trigger de-escalates agitation before further intervention.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
- A. Voice alteration
- B. Neck pain
- C. Tingling of the scalp
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect post-ECT.
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?
- A. Believes that his brother's death will be reversible
- B. Alienates himself from his peers
- C. Believes his bad behavior is causing his brother's death
- D. Regresses to an earlier developmental level
Correct Answer: A
Rationale: School-age children often see death as reversible, like sleep.
The client's prescription for erythromycin 500 mg four times per day.
A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?
- A. Medication
- B. Dosage
- C. Route
- D. Time
Correct Answer: C
Rationale: The route (e.g., PO, IV) is unspecified and requires clarification.