Nokea
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?
- A. Visual hallucination
- B. Gustatory hallucination
- C. Command hallucination
- D. Tactile hallucination
Correct Answer: C
Rationale: The correct answer is C: Command hallucination. This is the priority because command hallucinations can pose a direct threat to the client or others if the commands are harmful or dangerous. Addressing command hallucinations promptly is crucial to ensure the safety of the client and those around them. Visual hallucinations (A) may not necessarily lead to immediate harm. Gustatory hallucinations (B) involve taste sensations and are not typically associated with imminent danger. Tactile hallucinations (D) involve false perceptions of touch and are also less likely to result in immediate harm compared to command hallucinations.
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A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.
A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?
- A. Offer to make arrangements for the Sacrament of the Sick.
- B. Prepare to stay with the client's body after death until family arrives.
- C. Arrange for a member of the client's faith to bathe the body after death.
- D. Post a sign on the client's door stating, “No Talking.”
Correct Answer: A
Rationale: The correct answer is A: Offer to make arrangements for the Sacrament of the Sick. This is appropriate because the client is a practicing Roman Catholic, and the Sacrament of the Sick is a sacrament in the Catholic faith administered to the sick or dying. Offering to arrange for this sacrament shows respect for the client's religious beliefs and provides spiritual comfort.
Choice B is incorrect because staying with the client's body after death is not necessarily a religious practice and may not align with the client's beliefs. Choice C is incorrect as it assumes the client's faith requires a specific individual to bathe the body, which may not be the case for all Roman Catholics. Choice D is incorrect as it is not relevant to the client's religious needs and may hinder communication during this sensitive time.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
- A. A semi-private room across from the day room.
- B. A private room in a quiet location on the unit.
- C. A private room across from the exercise room.
- D. A semi-private room across from the snack area.
Correct Answer: B
Rationale: The correct answer is B: A private room in a quiet location on the unit. This choice minimizes stimuli and provides a calm environment, essential for managing manic symptoms. A quiet location reduces potential triggers for agitation or impulsivity. Semi-private rooms (A, D) may lead to conflicts with roommates. Rooms near common areas (C, D) can be noisy and disruptive. Overall, choice B promotes client safety and well-being during the manic phase.