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A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
- A. "Perhaps you could call your children to see how they are doing."
- B. "Don't worry. I'll take good care of your parent while you are gone."
- C. "You are feeling drawn in two separate directions."
- D. "There's nothing you can do here. You should go home to your children."
Correct Answer: C
Rationale: Rationale for Correct Answer C: The nurse should acknowledge the son's feelings of being torn between staying with his parent and going home to his children. This response demonstrates empathy and understanding of the son's emotional struggle, validating his concerns. By acknowledging his conflicting emotions, the nurse can help the son process his feelings and make a decision that aligns with his needs and responsibilities.
Summary of Incorrect Choices:
A: This response does not address the son's emotional conflict and does not offer support or validation.
B: This response focuses on the nurse's care for the parent, disregarding the son's emotional needs.
D: This response dismisses the son's concerns and suggests leaving without considering his emotional state or responsibilities.
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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
- A. Talk to the nursing staff.
- B. Talk to the client and identify the specific limits that are required of the client's behavior.
- C. Discuss the problem in a community meeting with the other clients on the unit present.
- D. Escort the client to her room each time the nurse observes the client socializing with others.
Correct Answer: B
Rationale: The correct initial action for the nurse to take is choice B: Talk to the client and identify the specific limits that are required of the client's behavior. This option is the most appropriate because it directly addresses the client's behavior and sets clear expectations. By having a one-on-one conversation with the client, the nurse can establish boundaries and consequences for disruptive behavior, which may help modify the client's actions. Talking to the nursing staff (choice A) may be necessary later, but addressing the client directly is the first step. Discussing the problem in a community meeting (choice C) may embarrass the client and not address the behavior directly. Escorting the client to her room (choice D) does not address the underlying issue of lying and disruptive behavior.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
- A. "I have heard that abusers try to keep their partner isolated from others."
- B. "I know that abusers lack social supports and social skills."
- C. "I know that men who are abusers gain power through intimidation."
- D. "I have heard that abusers think of themselves as important and have high self-esteem."
Correct Answer: D
Rationale: Answer D indicates a need for clarification because it presents a misconception about abusers. Abusers typically have low self-esteem and use power and control to compensate. This statement falsely suggests that abusers have high self-esteem and view themselves as important. This misunderstanding could lead to overlooking warning signs and risks associated with domestic violence. It's crucial for healthcare professionals to recognize the true dynamics of abusive relationships to provide appropriate support and interventions. Other choices (A, B, C) align with common knowledge about domestic violence, highlighting the tactics and behaviors typically associated with abusers.
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding?
- A. "I should expect tremors to start less than 24 hours after I stop drinking."
- B. "Disulfiram will block my cravings for alcohol."
- C. "My symptoms should last about 5 to 7 days once they begin."
- D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
Correct Answer: A
Rationale: The correct answer is A because alcohol withdrawal symptoms, including tremors, typically begin within 6-24 hours after the last drink. This statement shows an accurate understanding of the timing of alcohol withdrawal manifestations. Choice B is incorrect because Disulfiram is a medication used to deter alcohol consumption, not block cravings. Choice C is incorrect because alcohol withdrawal symptoms can last beyond 5-7 days. Choice D is incorrect because vitamin C does not prevent cirrhosis or liver damage from alcohol abuse.
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
- A. Agranulocytosis
- B. Akathisia
- C. Tardive dyskinesia
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). The client's symptoms of high fever, hypertension, and muscle rigidity are classic signs of NMS, a rare but life-threatening adverse effect of antipsychotic medications like haloperidol. NMS is a medical emergency that can lead to severe complications such as rhabdomyolysis, renal failure, and even death if not promptly recognized and treated. Agranulocytosis (A) is a potential side effect of some antipsychotic medications but typically presents with symptoms like fever and sore throat due to low white blood cell count. Akathisia (B) is a movement disorder characterized by restlessness and a compelling need to move, which is not consistent with the client's symptoms. Tardive dyskinesia (C) is a late-onset movement disorder associated with long-term antipsychotic use and typically presents with involuntary movements of the face and extremities, not fever
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has placed locks at the top of the doors leading to the outside.
- B. The partner has hired a house cleaner.
- C. The partner has lost 20 lb in the past 2 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 20 lb in the past 2 months indicates caregiver role strain. Significant weight loss can be a sign of stress, neglecting self-care, and being overwhelmed by caregiving responsibilities. This observation suggests that the partner may not be prioritizing their own well-being while caring for the client with Alzheimer's disease.
Choice A is incorrect because placing locks at the top of doors is a safety measure commonly taken to prevent the client with Alzheimer's disease from wandering outside unsupervised. Choice B is incorrect as hiring a house cleaner can be a practical solution to manage household tasks and does not necessarily indicate caregiver role strain. Choice D is incorrect because redirecting the client when frustrated is a positive caregiving technique to manage challenging behaviors.