Nokea
A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility. The client asks the nurse why he has to go "to that place." Which of the following responses should the nurse make?
- A. "Your doctor feels that this is the best place for you right now."
- B. "Why don't you ask your doctor about that when she comes in to see you?"
- C. "Did your doctor or anyone else talk to you about going to the nursing home?"
- D. "Your family can't take care of you at home, so you will need to go there."
Correct Answer: C
Rationale: Encouraging discussion allows the client to express concerns and ensures they are informed about their care plan.
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A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?
- A. Acute pancreatitis
- B. Slowed breathing
- C. Nasal septum perforation
- D. Permanent short-term memory loss
Correct Answer: B
Rationale: Heroin depresses the central nervous system, leading to respiratory depression.
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 in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.
A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.