Nokea
A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitamin B deficiency?
- A. A client who takes gabapentin as part of treatment for a seizure disorder.
- B. A client who has asthma.
- C. A client who has chronic alcohol use disorder.
- D. A client who takes heparin to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: A client who has chronic alcohol use disorder. Chronic alcohol use can lead to malabsorption of essential vitamins, including vitamin B. Alcohol interferes with the absorption and utilization of vitamin B, leading to a deficiency. This can result in various neurological and hematological complications. Clients with chronic alcohol use disorder are at high risk for vitamin B deficiency and should be closely monitored.
Incorrect Choices:
A: Gabapentin is not directly related to vitamin B deficiency.
B: Asthma does not directly increase the risk of vitamin B deficiency.
D: Heparin does not impact vitamin B levels significantly.
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A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
- A. "Tell me more about how you are feeling about your son's activities!"
- B. "You might want to use tutors to home-school him."
- C. "I agree. His well-being is the most important."
- D. "You sound overprotective. Let's talk about this some more."
Correct Answer: A
Rationale: The correct response is A: "Tell me more about how you are feeling about your son's activities!" This response demonstrates active listening and empathy, allowing the mother to express her concerns and fears openly. By understanding her perspective, the nurse can provide tailored education and support to address her specific worries regarding her son's activities. This approach fosters trust and collaboration between the nurse and the mother, leading to a more effective care plan for the child.
Incorrect responses:
B: "You might want to use tutors to home-school him." - This response does not address the mother's concerns directly and suggests an extreme solution without exploring the root of her fears.
C: "I agree. His well-being is the most important." - While well-being is essential, this response does not invite further discussion or address the mother's specific worries.
D: "You sound overprotective. Let's talk about this some more." - This response may come off as judgmental and dismissive of the mother's
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
Correct Answer: A
Rationale: Persecutory delusions involve irrational beliefs that one is being targeted or harmed by external forces.
A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?
- A. Tell the client that it is unlikely that he has bone cancer.
- B. Ask the client why he thinks the pain isn't a result of hiking.
- C. Suggest genetic testing so the client can understand his risks.
- D. Explain that the provider will see him and determine a course of action.
Correct Answer: D
Rationale: The nurse should provide reassurance while ensuring proper medical evaluation.
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?
- A. "It might help you feel better if you talk about it."
- B. "I'll just sit here with you for a few minutes then."
- C. "I understand. I've felt like that before, too."
- D. "Why are you feeling so down?"
Correct Answer: B
Rationale: The correct answer is B: "I'll just sit here with you for a few minutes then." This response demonstrates empathy and support without imposing solutions or pressuring the client to talk. It acknowledges the client's feelings and offers companionship, which can provide comfort and reassurance. Choice A may pressure the client to talk, which may not be what the client needs at the moment. Choice C shifts the focus to the nurse's own experiences, which may not be helpful for the client. Choice D may come across as confrontational or dismissive of the client's emotions. Therefore, choice B is the most appropriate response in this situation.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.