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A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake, and I won't let it take all of my blood. Which of the following responses should the nurse make?
- B. Your provider requires this blood specimen.
- C. You must be mistaken. Snakes cannot be in the clinic.
- D. I'm using a syringe to obtain your blood, not a snake.
- E. I don't see a snake, but that must be scary for you.
Correct Answer: D
Rationale: Acknowledging the client's hallucination and expressing empathy is the most appropriate response. By saying, 'I don't see a snake, but that must be scary for you,' the nurse acknowledges the client's fear and provides comfort without reinforcing the hallucination. This approach helps build trust and rapport, making it easier to proceed with the necessary procedure while ensuring the client's emotional wellbeing.
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A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. As long as a person is not vomiting after eating they do not have bulimia nervosa.
- B. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- C. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- D. People who have bulimia nervosa eat an average amount of food on a daily basis.
Correct Answer: C
Rationale: Bulimia nervosa can be difficult to detect because individuals with this disorder often maintain a weight that is within the average or ideal range. This can make it challenging for others to recognize the presence of an eating disorder, as the physical appearance may not immediately suggest a problem.
A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?
- A. The client goes to their room alone when they feel overwhelmed.
- B. The client displaces their feelings of self-harm until they talk to the provider.
- C. The client suppresses their feelings when they are angry.
- D. The client notifies the nurse when they want to harm themselves.
Correct Answer: D
Rationale: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.
A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?
- A. Provide a stimulating environment for the client.
- B. Offer the client several choices for daily activities and meals.
- C. Give the client clothing with elastic or fastening tape.
- D. Keep the bedroom dark while the client is sleeping.
Correct Answer: C
Rationale: Providing clothing with elastic or fastening tape simplifies the process of dressing and undressing, making it easier for the client to maintain independence in ADLs. This type of clothing can reduce frustration and promote a sense of autonomy, which is crucial for clients with Alzheimer's disease.
A nurse is reinforcing teaching with a client who has a new prescription for a nicotine transdermal system. Which of the following statements should the nurse make?
- A. A decrease in appetite is expected when beginning treatment.
- B. Using this medication will help minimize symptoms of withdrawal.
- C. Expect to stop smoking immediately after starting this medication.
- D. Apply a new patch every 4 hours until your cravings diminish.
Correct Answer: B
Rationale: Nicotine replacement therapy, including the nicotine transdermal system, is designed to help minimize symptoms of nicotine withdrawal. These symptoms can include cravings, irritability, anxiety, and difficulty concentrating. By providing a controlled release of nicotine, the transdermal system helps reduce the intensity of withdrawal symptoms and supports the quitting process.
A nurse is collecting data for a health history from a client who has bulimia nervosa. Which of the following laboratory findings should the nurse expect?
- A. Hypokalemia
- B. Leukopenia
- C. Decreased serum amylase
- D. Hematuria
Correct Answer: A
Rationale: Hypokalemia, or low potassium levels in the blood, is a common finding in individuals with bulimia nervosa, especially those who engage in frequent vomiting or use laxatives. Purging behaviors can lead to significant electrolyte imbalances, including potassium depletion, which can cause muscle weakness, cramps, and cardiac arrhythmias.