Nokea
A nurse is assessing a client experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Increased energy
- C. Increased cognitive awareness
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Chronic stress can lead to the release of stress hormones like cortisol and adrenaline, which can increase blood sugar levels. This occurs due to the body's fight-or-flight response to stress. Hypotension (A) is unlikely as stress typically leads to increased blood pressure. Increased energy (B) is less likely as chronic stress can lead to fatigue and exhaustion. Increased cognitive awareness (C) is not a common finding in chronic stress, as it can impair cognitive function. Hyperglycemia (D) is the most likely finding due to the physiological response to stress.
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A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse’s priority?
- A. Monitor for risk of self-harm.
- B. Administer prescribed antidepressants.
- C. Encourage adequate fluid intake.
- D. Assist with activities of daily living.
Correct Answer: A
Rationale: The correct answer is A: Monitor for risk of self-harm. This is the priority because individuals with major depressive disorder are at an increased risk for suicide. The nurse must ensure the client's safety by closely monitoring for any signs of self-harm or suicidal ideation. Administering antidepressants (B) may be important for long-term management but ensuring immediate safety takes precedence. Encouraging fluid intake (C) and assisting with activities of daily living (D) are important aspects of care but do not address the immediate risk of self-harm.
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
- A. Decreased auditory and visual acuity
- B. Decreased display of emotions
- C. Personality traits that are opposite of original traits
- D. Forgetfulness gradually progressing to disorientation
Correct Answer: D
Rationale: Dementia typically presents with progressive forgetfulness and eventual disorientation.
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Rotate assignment of daily caregivers.
- B. Provide an activity schedule that changes from day to day.
- C. Limit time for the client to perform activities.
- D. Talk the client through tasks one step at a time.
Correct Answer: D
Rationale: Clients with Alzheimer's benefit from structured routines and step-by-step guidance.
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
- A. "You are being unreasonable, and I will not call your doctor at this hour."
- B. "I can't call a doctor in the middle of the night unless it's an emergency."
- C. "Go back to your room, and I'll try to get in touch with your doctor."
- D. "You must be very upset about something."
Correct Answer: D
Rationale: The correct answer is D: "You must be very upset about something." This response is appropriate because it acknowledges the client's emotions and demonstrates empathy. It shows the nurse's understanding of the client's distress, which is crucial in building a therapeutic relationship. By validating the client's feelings, the nurse can de-escalate the situation and gather more information to address the client's needs effectively.
Choice A is incorrect because it dismisses the client's request and can escalate the situation. Choice B is incorrect as it fails to acknowledge the client's emotions and lacks empathy. Choice C is incorrect as it does not address the client's emotional state and may lead to further agitation.
How should a nurse address compulsive behaviors in a newly admitted client with OCD?
- A. Isolate the client
- B. Confront the client about the behavior
- C. Encourage participation in group activities
- D. Set strict limits on behaviors
- E. Allow additional time for rituals
Correct Answer: D
Rationale: Correct Answer: D. Set strict limits on behaviors
Rationale:
1. Setting strict limits helps establish boundaries and structure for the client.
2. It assists in reducing compulsive behaviors by providing clear guidelines.
3. It promotes a sense of control and safety for the client.
4. Allows for gradual exposure and response prevention therapy.
Summary:
A: Isolating the client can exacerbate feelings of loneliness and increase anxiety.
B: Confrontation may trigger defensiveness and hinder therapeutic rapport.
C: While group activities can be beneficial, they may not directly address the compulsive behaviors.
E: Allowing additional time for rituals reinforces maladaptive behaviors.