Nokea
A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This behavior indicates which of the following findings?
- A. The client is ready for discharge.
- B. The client is able to function independently.
- C. The client may be having a recurrence of delirium tremens.
- D. The client is exhibiting dependency.
Correct Answer: D
Rationale: The correct answer is D: The client is exhibiting dependency. This behavior indicates that the client is relying on the nurse for permission before performing activities of daily living, suggesting a level of dependency. This is common in clients with delirium tremens as they may have cognitive impairment and need guidance for decision-making.
A: The client seeking permission does not necessarily indicate readiness for discharge.
B: The client seeking permission does not necessarily indicate ability to function independently.
C: There is no indication of a recurrence of delirium tremens based on seeking permission.
Summary: The correct answer, D, is supported by the client's behavior of seeking permission, indicating dependency. Other choices are incorrect as they do not align with the behavior exhibited by the client in this scenario.
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A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?
- A. "Evidence must exist prior to reporting."
- B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it."
- C. "I don't want to defame someone if the report is false."
- D. "If suspicion of abuse exists, then reporting is mandatory."
Correct Answer: D
Rationale: The correct answer is D: "If suspicion of abuse exists, then reporting is mandatory." This statement is correct because as a healthcare professional, it is crucial to report any suspicion of child abuse to protect the child's safety. Reporting is mandatory to ensure that appropriate actions are taken to investigate and prevent harm to the child.
A: "Evidence must exist prior to reporting." - This statement is incorrect because suspicion alone is enough to trigger reporting, and waiting for evidence may delay intervention and put the child at risk.
B: "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." - This statement is incorrect as it is the responsibility of healthcare workers to report suspected abuse regardless of promises made by the potential abuser.
C: "I don't want to defame someone if the report is false." - This statement is incorrect because the focus should be on the safety and well-being of the child, and reporting suspicions of abuse is not about def
A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?
- A. "You will need to consume a low-salt diet while on this medication."
- B. "You will need your blood levels drawn weekly during the first month."
- C. "You will need to take this medication on an empty stomach."
- D. "You will need to stop this medication if you experience diarrhea."
Correct Answer: B
Rationale: Lithium levels need frequent monitoring at the start of therapy to prevent 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 caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions that could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions?
- A. Pancreatitis
- B. Cholecystitis
- C. Tuberculosis
- D. Hypothyroidism
Correct Answer: D
Rationale: The correct answer is D: Hypothyroidism. Major depressive episodes can be a symptom of hypothyroidism due to the impact of thyroid hormones on mood regulation. Diagnostic testing for hypothyroidism typically includes measuring levels of thyroid-stimulating hormone (TSH) and free thyroxine (T4). Pancreatitis (A) and cholecystitis (B) are conditions primarily related to the gastrointestinal system and do not typically present with depressive symptoms. Tuberculosis (C) is an infectious disease affecting the lungs and other organs, but it does not directly cause major depressive episodes. Therefore, ruling out hypothyroidism through diagnostic testing is the most relevant in this case.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.