Nokea
A nurse is caring for a client who has delusional behavior and states, 'I can’t go to group therapy today. I am expecting a high-level official to visit me.' The nurse responds, 'I understand, but it is time for group therapy and we expect everyone to attend. Let’s walk over together.' For which of the following reasons is the nurse’s response considered therapeutic?
- A. It clearly articulates the expectations of the client.
- B. It demonstrates empathy towards the client.
- C. It sets limits on the client’s manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: B
Rationale: The correct answer is B: It demonstrates empathy towards the client. By acknowledging the client's feelings and showing understanding, the nurse is building a therapeutic relationship based on empathy. This approach helps the client feel heard and validated, fostering trust and cooperation. The other choices are incorrect because: A) while the response does articulate expectations, it does not address the client's emotions or perspective; C) while setting limits is important, the response does not directly address manipulative behavior; D) reflection involves paraphrasing or summarizing the client's thoughts, which is not evident in the nurse's response.
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A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperglycemia
- C. Dehydration
- D. Polyphagia
Correct Answer: C
Rationale: The correct answer is C: Dehydration. In diabetes insipidus, there is a deficiency of antidiuretic hormone leading to excessive urine output, causing dehydration. Bradycardia (A) is not typically associated. Hyperglycemia (B) is seen in diabetes mellitus, not diabetes insipidus. Polyphagia (D) is excessive hunger, which is not a common symptom of diabetes insipidus.
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
- A. Creatinine
- B. Aspartate aminotransferase (AST)
- C. Amylase
- D. Antidiuretic hormone (ADH)
Correct Answer: B
Rationale: The correct answer is B: Aspartate aminotransferase (AST). The nurse should prioritize assessing AST because both alcohol consumption and acetaminophen use can lead to liver damage. Elevated AST levels indicate liver injury, making it crucial to monitor for potential hepatotoxicity in this client. Creatinine (choice A) is typically assessed to evaluate kidney function, not directly related to alcohol or acetaminophen use. Amylase (choice C) is an enzyme related to pancreas health, not specifically affected by alcohol or acetaminophen. Antidiuretic hormone (ADH - choice D) is related to fluid balance, not a priority in this scenario. By focusing on AST, the nurse can promptly identify any liver damage and intervene accordingly.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?
- A. Ulnar deviation
- B. Symmetric joints affected
- C. Pain worsens with activity
- D. Weight loss
Correct Answer: C
Rationale: The correct answer is C: Pain worsens with activity. In osteoarthritis, pain typically worsens with movement or activity due to the degeneration of joint cartilage causing friction between bones. This is a hallmark symptom of osteoarthritis. Ulnar deviation (A) is more commonly seen in rheumatoid arthritis. Symmetric joints affected (B) is also more characteristic of rheumatoid arthritis rather than osteoarthritis. Weight loss (D) is not a typical manifestation of osteoarthritis, unless it is due to decreased physical activity from pain.
A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
- A. Intense pruritus
- B. Irregular borders
- C. Uniform pigmentation
- D. Purulent drainage
Correct Answer: B
Rationale: The correct answer is B: Irregular borders. Irregular borders are a classic sign of malignancy in nevi, suggesting potential melanoma. This finding indicates that the nevus may be evolving into a cancerous lesion. It is crucial for the nurse to report this to the provider promptly for further evaluation. Intense pruritus (choice A) is common in benign nevi and not specific to malignancy. Uniform pigmentation (choice C) is typically seen in benign nevi and is not a concerning feature. Purulent drainage (choice D) is more indicative of infection or inflammation rather than malignancy. In summary, irregular borders are a red flag for malignancy, while the other choices are more likely associated with benign nevi or other conditions.