Nokea
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?
- A. "Do not worry about that. Your wife will be fine."
- B. "I think you should calm down a little before you see your partner."
- C. "Why do you think the crash is your fault?"
- D. "Tell me more about your feelings about what happened to your partner."
Correct Answer: D
Rationale: Encouraging the partner to express emotions helps with emotional processing and coping.
You may also like to solve these questions
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
- A. Lock the doors to the unit and secure windows so they cannot be opened.
- B. Provide the client with plastic eating utensils for meals.
- C. Remove any objects from the client's environment that could be used for self-harm.
- D. Assign a staff member to stay with the client at all times.
Correct Answer: D
Rationale: A client who refuses a safety contract is at high risk, requiring constant supervision to ensure safety.
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?
- A. The client is a danger to herself or others.
- B. The client is unwilling to accept that treatment is needed.
- C. The client states that she does not like the neighbor.
- D. The client states that she plans to move out of the state immediately.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse can keep the client in the hospital after the 72-hour hold if the client is deemed a danger to herself or others. This is crucial in ensuring the safety of the client and others. It indicates that the client poses a significant risk of harm, warranting further evaluation and treatment.
Incorrect Choices:
B: The client's willingness to accept treatment is important, but it does not solely determine if the client can be kept in the hospital.
C: Personal preferences or dislikes are not sufficient reasons to detain a client after the hold is over.
D: Planning to move out of the state does not address the immediate safety concerns that necessitate continued hospitalization.
A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This behavior indicates which of the following findings?
- A. The client is ready for discharge.
- B. The client is able to function independently.
- C. The client may be having a recurrence of delirium tremens.
- D. The client is exhibiting dependency.
Correct Answer: D
Rationale: The correct answer is D: The client is exhibiting dependency. This behavior indicates that the client is relying on the nurse for permission before performing activities of daily living, suggesting a level of dependency. This is common in clients with delirium tremens as they may have cognitive impairment and need guidance for decision-making.
A: The client seeking permission does not necessarily indicate readiness for discharge.
B: The client seeking permission does not necessarily indicate ability to function independently.
C: There is no indication of a recurrence of delirium tremens based on seeking permission.
Summary: The correct answer, D, is supported by the client's behavior of seeking permission, indicating dependency. Other choices are incorrect as they do not align with the behavior exhibited by the client in this scenario.
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
- A. Telling his parents that he doesn't want to talk about the suicide attempt.
- B. Stating that he wants to be with his peers more than with his parents.
- C. Preferring to eat his meals while watching TV.
- D. Planning to give his CD collection to his girlfriend.
Correct Answer: D
Rationale: The correct answer is D: Planning to give his CD collection to his girlfriend. This behavior indicates the adolescent is making future plans involving giving away possessions, which could be a sign of continued suicidal ideation. Giving away prized possessions is often seen as a way of saying goodbye or preparing for death. Choices A, B, and C do not necessarily indicate ongoing suicidal intent. A may suggest avoidance, B may indicate a desire for peer support, and C may be a personal preference. Therefore, D is the most concerning behavior that warrants immediate attention.
A nurse in a mental health facility is preparing to interview a client who has schizophrenia. Which of the following actions should the nurse take?
- A. Sit on the other side of a table from the client.
- B. Place the client in a chair higher than the nurse.
- C. Start the interview with a question the client can answer with “yes” or "no."
- D. Sit beside the client rather than facing him.
Correct Answer: C
Rationale: The correct answer is C: Start the interview with a question the client can answer with “yes” or "no." This approach is recommended for clients with schizophrenia to establish rapport and ease anxiety. It allows the client to engage in a simple way, reducing the pressure of providing complex answers. Sitting on the other side of a table (A) may create a barrier, placing the client in a higher chair (B) may be perceived as intimidating, and sitting beside the client (D) may invade personal space. The other choices do not promote effective communication or rapport-building.