Nokea
A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.
- A. panic attacks
- B. impaired short-term memory
- C. auditory hallucinations
- D. inability to leave home
Correct Answer: A,D
Rationale: Agoraphobia involves panic attacks and fear of leaving safe environments, leading to inability to leave home. Memory issues and hallucinations are not typical.
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The nurse observes that a client is restless, tense, and reports feeling empty. The nurse notes the client has a history of threatening self-mutilation. Which nursing action is appropriate?
- A. Monitor weight and dietary intake.
- B. Administer chlordiazepoxide.
- C. Provide food in client's own containers.
- D. Take inventory of the client's room.
Correct Answer: D
Rationale: Taking inventory of the client’s room ensures safety by identifying and removing potential tools for self-harm, given the history of threatened self-mutilation. Other actions do not directly address the immediate risk.
A client diagnosed with Raynaud's disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change should the nurse teach the client to consider to help alleviate his stress?
- A. Change to a less stressful job.
- B. Seek help from a psychologist.
- C. Consider a stress management program.
- D. Use earplugs to minimize environmental noise.
Correct Answer: C
Rationale: Stress can trigger the vasospasm that occurs with Raynaud's disease, so referral to a stress management program or the use of biofeedback training may be helpful. Option 1 is unrealistic. Option 2 is not necessarily required at this time. Option 4 does not specifically address the subject.
The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?
- A. Amoxicillin is an antibiotic that will help you get well.
- B. This medicine tastes just like fresh strawberries.
- C. You can't drink anything for an hour after taking this medicine.
- D. If you don't want to drink this medicine, I can give you a shot instead.
Correct Answer: A
Rationale: Informing the client that amoxicillin is an antibiotic that will help them recover provides age-appropriate education about the medication’s purpose, promoting understanding and adherence. Other options may mislead or unnecessarily alarm the child.
The nurse admits a client diagnosed with Alzheimer disease. The client is mildly anxious and very confused. Which action does the nurse take?
- A. Remain with the client and begin explaining the environment.
- B. Give the client a copy of the unit rules and procedures.
- C. Ask the client to sign a consent form for medications.
- D. Orient the client to self, day, time, place, and situation.
Correct Answer: D
Rationale: Orienting the client to self, day, time, place, and situation addresses confusion and anxiety, providing a calming and grounding effect. Explaining the environment is helpful but less structured, and rules or consent forms are inappropriate given the client’s confusion.
Based on Maslow's hierarchy of needs, which client is demonstrating characteristics of self-actualization?
- A. Client is competent and esteemed by others for accomplishing work goals
- B. Client maintains a stable, loving, same-sex partnership for several years
- C. Client learns to sublimate aggressive impulses using physical exercises
- D. Client has an accurate perception of reality and is accepting of self and others
Correct Answer: D
Rationale: According to Maslow's hierarchy of needs, self-actualization is the highest level where individuals strive to reach their full potential and achieve personal growth. A self-actualized person, as per Maslow, has an accurate perception of reality and is accepting of themselves and others. This individual is characterized by traits such as fairness, independence, spontaneity, and creativity. While choices A, B, and C represent important aspects of human needs fulfillment, they align more closely with lower levels in Maslow's hierarchy. Choice A refers to meeting self-esteem needs, choice B relates to love and belonging needs, and choice C addresses safety needs, all of which are below self-actualization in the hierarchy of needs.