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A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?
- A. Schedule the teaching sessions for a long time to promote participation.
- B. Use 'I' statements rather than 'you' statements.
- C. Assist the clients with establishing long-term goals.
- D. Ensure the teaching sessions occur right before bedtime.
Correct Answer: B
Rationale: Using 'I' statements rather than 'you' statements helps build rapport and reduces defensiveness. It fosters a supportive learning environment, making communication more effective for older adults.
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A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?
- A. A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
- B. A client who is standing in her room, yelling obscenities, and throwing her clothes.
- C. A client who has bipolar disorder and is continuously pacing at the end of the hall.
- D. A client in the dayroom who is screaming at other clients about what is on the television.
Correct Answer: B
Rationale: A client yelling obscenities and throwing clothes poses a more direct risk due to potential escalation to physical harm. This behavior requires immediate attention over anxiety, pacing, or verbal disruptions.
A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?
- A. Therapeutic hold.
- B. Restraint.
- C. Diversion.
- D. Timeout.
Correct Answer: D
Rationale: Timeout allows the client to have a moment away from stimuli to regain control and calm down, which is a recognized de-escalation technique. This matches the client’s request and supports de-escalation efforts.
Nurses' Notes
Admission: Client restless during the night, attempting to get out of bed and placing bedcovers on the floor. Has been incontinent of urine twice. Client instructed on use of urinal and told to call for assistance by using the call light. Confuses the call light with the television remote control. Disoriented to time, place, person, and situation. Unable to recall home address. Was unable to assist with bath this morning; when handed the washcloth to clean their face, client asked, "Do you want me to put this in the dryer?"
Medical History
A 76-year-old client fell at home, resulting in fractured humerus and multiple abrasions to arms. Client is unable to recall what precipitated the fall, and physical examination reveals no injury to the client's head. Client has a history of hypertension controlled with atenolol. Client lives with partner and adult children visit client every few months.
A nurse is caring for a 76-year-old female client who experienced a fall.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
- A. Expected aging process,Alzheimer's disease,Major depressive disorder,Delirium
- B. Determine the date of the client's last eye examination,Use symbols rather than written signs for directions, Anticipate a prescription for donepezil,Anticipate a prescription for duloxetine.
- C. Night vision,Presence of agnosia,Ability to complete familiar tasks,Oxygen saturation
Correct Answer: B
Rationale: Alzheimer’s explains chronic confusion and task difficulty. Using symbols aids navigation, donepezil manages symptoms, and monitoring agnosia and familiar tasks tracks progression.
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?
- A. Bupropion.
- B. Risperidone.
- C. Aripiprazole.
- D. Quetiapine.
Correct Answer: A
Rationale: Bupropion is an antidepressant also used to aid smoking cessation by reducing cravings and withdrawal symptoms. It’s specifically indicated for this purpose.
A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
- A. Diarrhea.
- B. Hypokinesis.
- C. Bradycardia.
- D. Meiosis.
Correct Answer: A
Rationale: Diarrhea is a common symptom of opioid withdrawal due to increased gastrointestinal motility. This reflects the body’s reaction to the absence of opioids.