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A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?
- A. I can encourage my child to think about what they did that allowed this event to happen.
- B. I anticipate that my child will feel some self-blame.
- C. I should encourage my child to focus solely on the future.
- D. I will have to do all I can to monitor my child's relationships.
Correct Answer: D
Rationale: Actively monitoring the adolescent's relationships can demonstrate vigilance and support, helping to create a safe environment for recovery. This shows a proactive, protective stance, indicative of a positive support system.
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A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can discuss a client's information with staff who have provided care in the past.
- B. A client retains the legal right to privacy of health information even after they have died.
- C. The provider must give consent to discuss health information with the client's family.
- D. A provider may speak to a client's employer regarding a substance use disorder.
Correct Answer: B
Rationale: Clients retain the legal right to privacy of health information even after death, per HIPAA regulations. This statement reflects an accurate understanding of confidentiality principles.
A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- B. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- C. People who have bulimia nervosa eat an average amount of food on a daily basis.
- D. As long as a person is not vomiting after eating, they do not have bulimia nervosa.
Correct Answer: B
Rationale: Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder less visible. This highlights a key characteristic for community education.
Nurses' Notes
Admission: Client restless during the night, attempting to get out of bed and placing bedcovers on the floor. Has been incontinent of urine twice. Client instructed on use of urinal and told to call for assistance by using the call light. Confuses the call light with the television remote control. Disoriented to time, place, person, and situation. Unable to recall home address. Was unable to assist with bath this morning; when handed the washcloth to clean their face, client asked, "Do you want me to put this in the dryer?"
Medical History
A 76-year-old client fell at home, resulting in fractured humerus and multiple abrasions to arms. Client is unable to recall what precipitated the fall, and physical examination reveals no injury to the client's head. Client has a history of hypertension controlled with atenolol. Client lives with partner and adult children visit client every few months.
A nurse is caring for a 76-year-old female client who experienced a fall.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
- A. Expected aging process,Alzheimer's disease,Major depressive disorder,Delirium
- B. Determine the date of the client's last eye examination,Use symbols rather than written signs for directions, Anticipate a prescription for donepezil,Anticipate a prescription for duloxetine.
- C. Night vision,Presence of agnosia,Ability to complete familiar tasks,Oxygen saturation
Correct Answer: B
Rationale: Alzheimer’s explains chronic confusion and task difficulty. Using symbols aids navigation, donepezil manages symptoms, and monitoring agnosia and familiar tasks tracks progression.
Nurses' Notes
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED). Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.
- A. Maintain a low stimulation environment.
- B. Alternate nursing staff daily.
- C. Provide client with limited information about diagnosis.
- D. Approach client slowly.
- E. Reorient client to person, place, and time frequently.
Correct Answer: A,D,E
Rationale: Maintaining a low stimulation environment, approaching slowly, and frequent reorientation address delirium symptoms by reducing agitation, building trust, and improving orientation, based on the client’s confused state.
A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.