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A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?
- A. Gradual onset
- B. Impaired judgment
- C. Difficulty swallowing
- D. Slowed, flat speech
Correct Answer: B
Rationale: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.
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A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?
- A. Determine whether the client's goals are met.
- B. Collect data about the client's current health status.
- C. Provide the client with information on problem-solving.
- D. Establish a regular meeting time with the client.
Correct Answer: C
Rationale: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health.
A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom area dark at night.
- B. Have the client exercise 30 minutes before bedtime.
- C. Place the client's mattress on the bedroom floor.
- D. Encourage the client to nap often during the day.
Correct Answer: C
Rationale: Placing the client's mattress on the bedroom floor is a practical safety measure for clients with Alzheimer's disease who wander at night. This approach minimizes the risk of injury from falls, as the client will be closer to the ground. By reducing the height of the bed, families can create a safer sleeping environment and help prevent potential injuries due to wandering and confusion.
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 charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says
- A. I heard that Mr. Smith was admitted for a suicide attempt. Which of the following responses should the charge nurse make?
- B. I will be informing the provider about this conversation.
- C. You should continue this conversation in a private place.
- D. It is an invasion of privacy to discuss that information.
- E. If you are going to talk about a client in public, do not use their name.
Correct Answer: C
Rationale: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.
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.