Nokea
A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
- A. "I will take my dose of orlistat every morning an hour before breakfast."
- B. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
- C. "I will eat a no-fat diet to prevent side effects from the medication."
- D. "I will feel less hungry during meals while I am taking orlistat."
Correct Answer: B
Rationale: The correct answer is B: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine can be a sign of liver injury, a serious side effect of orlistat. The client recognizing this symptom and knowing to contact the doctor promptly demonstrates comprehension of the medication's potential risks.
A: "I will take my dose of orlistat every morning an hour before breakfast." - This statement does not indicate understanding of the medication's specific instructions.
C: "I will eat a no-fat diet to prevent side effects from the medication." - While a low-fat diet is recommended with orlistat, this statement does not address potential serious side effects.
D: "I will feel less hungry during meals while I am taking orlistat." - This statement does not address the medication's side effects or potential risks.
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A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
- A. Honk the car horn to get the client's attention.
- B. Calmly speak the client's name out of the car window.
- C. Keep driving in a path that is going away from the client's house.
- D. Stop the car in the client's driveway and call the authorities.
Correct Answer: C
Rationale: Leaving the situation and seeking help from authorities is the safest course of action.
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.
A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
- A. "You are being unreasonable, and I will not call your doctor at this hour."
- B. "I can't call a doctor in the middle of the night unless it's an emergency."
- C. "Go back to your room, and I'll try to get in touch with your doctor."
- D. "You must be very upset about something."
Correct Answer: D
Rationale: The correct answer is D: "You must be very upset about something." This response is appropriate because it acknowledges the client's emotions and demonstrates empathy. It shows the nurse's understanding of the client's distress, which is crucial in building a therapeutic relationship. By validating the client's feelings, the nurse can de-escalate the situation and gather more information to address the client's needs effectively.
Choice A is incorrect because it dismisses the client's request and can escalate the situation. Choice B is incorrect as it fails to acknowledge the client's emotions and lacks empathy. Choice C is incorrect as it does not address the client's emotional state and may lead to further agitation.
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
- A. Lock the doors to the unit and secure windows so they cannot be opened.
- B. Provide the client with plastic eating utensils for meals.
- C. Remove any objects from the client's environment that could be used for self-harm.
- D. Assign a staff member to stay with the client at all times.
Correct Answer: D
Rationale: A client who refuses a safety contract is at high risk, requiring constant supervision to ensure safety.