Nokea
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
- A. Voice alteration
- B. Neck pain
- C. Tingling of the scalp
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect post-ECT.
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The client tells the nurse they do not want to be resuscitated in the event of a cardiac arrest.
A nurse is caring for a client who has lung cancer. The client tells the nurse they do not want to be resuscitated in the event of a cardiac arrest. Which of the following statements should the nurse make?
- A. Let me explain the pros and cons of your decision.
- B. I will support your decision and help you explain it to others.
- C. I will send the social worker in to discuss this decision with you.
- D. I suggest you discuss this decision with your family first.
Correct Answer: B
Rationale: Supporting the client's decision respects autonomy and facilitates communication, aligning with ethical care.
The client delivered a newborn by cesarean birth 1 day ago.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You can apply counterpressure to your back with each position change.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You should use patterned-paced breathing when changing positions.
Correct Answer: C
Rationale: Splinting the incision with a pillow reduces pain during movement.
The client reports having trouble getting to sleep at night.
A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?
- A. Remain in bed until you fall asleep.
- B. Keep the television volume low while you are trying to fall asleep.
- C. Sleep longer hours on the weekend.
- D. Establish a daily exercise routine.
Correct Answer: D
Rationale: A daily exercise routine promotes better sleep patterns.
The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.
A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching?
- A. Carry your newborn back to the nursery in your arms when you need to rest.
- B. Request that the nurses show their nursing license prior to removing your newborn from the room.
- C. Alert the staff if any of your newborn's identification bands are missing.
- D. Leave your newborn in the bassinet in your room while you use the bathroom.
Correct Answer: C
Rationale: Missing ID bands increase abduction risk, requiring immediate staff notification.