Nokea
A nurse is receiving report on four clients at the beginning of the shift. Which of the following clients should the nurse check first?
- A. A client who is hearing command hallucinations.
- B. A client who is verbalizing ideas of reference.
- C. A client who is using neologisms.
- D. A client who is demonstrating clang associations.
Correct Answer: A
Rationale: A client who is hearing command hallucinations should be prioritized first because command hallucinations can be particularly dangerous. These hallucinations can involve voices instructing the client to harm themselves or others. Immediate assessment and intervention are crucial to ensure the client's safety and to prevent potential harm.
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A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?
- A. The client goes to their room alone when they feel overwhelmed.
- B. The client displaces their feelings of self-harm until they talk to the provider.
- C. The client suppresses their feelings when they are angry.
- D. The client notifies the nurse when they want to harm themselves.
Correct Answer: D
Rationale: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.
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. As long as a person is not vomiting after eating they do not have bulimia nervosa.
- B. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- C. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- D. People who have bulimia nervosa eat an average amount of food on a daily basis.
Correct Answer: C
Rationale: Bulimia nervosa can be difficult to detect because individuals with this disorder often maintain a weight that is within the average or ideal range. This can make it challenging for others to recognize the presence of an eating disorder, as the physical appearance may not immediately suggest a problem.
A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says
- A. I heard that Mr. Smith was admitted for a suicide attempt. Which of the following responses should the charge nurse make?
- B. I will be informing the provider about this conversation.
- C. You should continue this conversation in a private place.
- D. It is an invasion of privacy to discuss that information.
- E. If you are going to talk about a client in public, do not use their name.
Correct Answer: C
Rationale: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.
A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?
- A. Inform the parents that the findings must be reported to authorities.
- B. Complete an incident report for risk management.
- C. Interview the child about the suspected abuse with a parent present.
- D. Avoid asking the child what caused the injury.
Correct Answer: A
Rationale: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.
A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?
- A. Provide a stimulating environment for the client.
- B. Offer the client several choices for daily activities and meals.
- C. Give the client clothing with elastic or fastening tape.
- D. Keep the bedroom dark while the client is sleeping.
Correct Answer: C
Rationale: Providing clothing with elastic or fastening tape simplifies the process of dressing and undressing, making it easier for the client to maintain independence in ADLs. This type of clothing can reduce frustration and promote a sense of autonomy, which is crucial for clients with Alzheimer's disease.