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A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?
- A. Making a unit calendar to promote orientation.
- B. Discussing childhood memories during group therapy.
- C. Encouraging thought-stopping to block undesirable thoughts.
- D. Playing board games with other clients to enhance cognition.
Correct Answer: B
Rationale: Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults. This aligns with the goals of reminiscence therapy, unlike orientation aids or thought-stopping.
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A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse
- A. This baby constantly cries. My partner works all the time
- B. and I can't take any more.' Which of the following responses is the nurse’s priority?
- C. Have you discussed this with your partner.
- D. Do you have a friend who could help you.
- E. Tell me about your baby.
- F. Have you tried any soothing techniques for your baby.
Correct Answer: C
Rationale: Asking about the baby’s current condition immediately assesses safety and well-being, which is the nurse’s priority. This ensures potential risks, like postpartum depression or infant harm, are addressed first.
Nurses' Notes
0205: Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified. Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular. During data collection, client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
0415: Client's adult child arrived to the ED and went to client's room. Client identified family member. Client is pacing and agitated, and states, "I don't understand why I am here." Adult child asks nurse to talk outside of room and states, "I don't know why they are so confused. They are not normally like this." Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED).For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
- A. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
- B. Administer lorazepam.
- C. Initiate 1:1 supervision.
- D. Administer acyclovir.
Correct Answer: A,B,C
Rationale: IV fluids address dehydration, lorazepam manages agitation or withdrawal, and 1:1 supervision ensures safety due to delirium. Acyclovir is unexpected as no viral infection is indicated.
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
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?
- A. Reaction formation.
- B. Somatization.
- C. Sublimation.
- D. Intellectualization.
Correct Answer: B
Rationale: Somatization involves the transformation of anxiety into physical symptoms, such as pain or fatigue, without a medical cause. This is a way the body expresses psychological distress through physical symptoms, aligning with the client’s behavior.
A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. Currently married.
- B. Access to guns in the home.
- C. Terminal liver cancer.
- D. Alcohol use disorder.
Correct Answer: B,C,D
Rationale: Access to guns in the home, terminal liver cancer, and alcohol use disorder are significant risk factors for suicide. Guns increase lethality, terminal illness causes distress, and alcohol impairs judgment and increases impulsivity, all elevating suicide risk.