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A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?
- A. Arrange for the sibling to visit the client in the dayroom.
- B. Refer the sibling to the client's provider.
- C. Tell the sibling the client does not want visitors.
- D. Encourage the client to visit with the sibling.
Correct Answer: C
Rationale: Informing the sibling that the client does not want visitors respects the client’s wishes and maintains their autonomy and confidentiality. This action upholds the client’s rights without pressuring them.
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A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique?
- A. I should use role-playing to enhance new behavioral skills.
- B. I should move closer to my child when they are agitated.
- C. I should ignore attention-seeking behaviors.
- D. I should re-engage my child in an appropriate activity.
Correct Answer: D
Rationale: Re-engaging the child in an appropriate activity is a key part of the redirection technique. It helps divert the child's attention away from the undesired behavior and encourages positive behavior, showing the parent understands this approach.
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.
A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?
- A. Schedule the teaching sessions for a long time to promote participation.
- B. Use 'I' statements rather than 'you' statements.
- C. Assist the clients with establishing long-term goals.
- D. Ensure the teaching sessions occur right before bedtime.
Correct Answer: B
Rationale: Using 'I' statements rather than 'you' statements helps build rapport and reduces defensiveness. It fosters a supportive learning environment, making communication more effective for older adults.
A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects
- A. the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?
- B. Liver enzymes.
- C. Sodium level.
- D. Uric acid.
- E. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Sodium levels must be monitored while taking lithium because lithium can alter sodium and fluid balance. Changes in sodium levels can affect lithium levels and potentially lead to toxicity, making this a critical monitoring parameter.
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
- A. Place a lock at the top of doors leading outside.
- B. Use light restraints while the client is in bed.
- C. Administer an antianxiety medication before bedtime.
- D. Encourage the client to nap during the day.
Correct Answer: A
Rationale: Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety. This is a practical, non-restrictive measure to manage nighttime wandering in Alzheimer’s.