Nokea
A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches,the client states I am at the end of my rope. I don’t think I can take any more bad news. Which of the following responses should the nurse make?
- A. An anti-anxiety pill works best for situations like this.
- B. Most clients with anxiety issues benefit from lying down.
- C. Providers usually recommend relaxation exercises for clients who are as upset as you are.
- D. Come with me to an area where we can talk without interruption.
Correct Answer: D
Rationale: Inviting the client to a quiet area offers support and encourages expression of concerns.
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A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
- A. Systemic lupus erythematosus
- B. Placental abruption
- C. Heparin therapy for deep-vein thrombosis
- D. Warfarin therapy for atrial fibrillation
Correct Answer: C
Rationale: Rationale: Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of heparin therapy, causing a drop in platelet count. The correct answer is C because heparin therapy for deep-vein thrombosis is a known risk factor for HIT. Systemic lupus erythematosus (choice A) is associated with other complications but not specifically HIT. Placental abruption (choice B) is a condition related to pregnancy complications. Warfarin therapy for atrial fibrillation (choice D) is not a risk factor for HIT. Therefore, the nurse should focus on heparin therapy as a significant risk factor in HIT education.
Susan,the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?
- A. Lethality of the method and availability of means
- B. Client's educational and economic background
- C. Client's insight into the reasons for the decision
- D. Quality of the client's social support
Correct Answer: A
Rationale: The correct answer is A. Assessing the lethality of the method and availability of means is the priority because it directly addresses the client's immediate safety. Understanding how easily the client can access the means to commit suicide is crucial in preventing harm. Choices B, C, and D are important aspects of a comprehensive assessment but do not directly address the immediate risk of suicide. Choice B focuses on background information, which may be relevant for understanding the client but is not the priority in this urgent situation. Choice C pertains to the client's insight, which is important for therapeutic interventions but does not address the imminent risk. Choice D considers social support, which is valuable in long-term prevention but not the immediate concern.
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?
- A. Why did you make the choice to behave negatively?
- B. I understand that you are angry. However, I followed the appropriate protocol.
- C. You need to calm down and forgive me before discussing this matter any further.
- D. You were made aware of the consequences of negative behavior, so you better go to your room.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions while also asserting boundaries and explaining the nurse's actions. By stating, "I understand that you are angry. However, I followed the appropriate protocol," the nurse shows empathy towards the client's feelings and also maintains professionalism by emphasizing adherence to established procedures. This response validates the client's emotions and provides clarity on the nurse's decision-making process, promoting open communication and understanding.
Choices A, C, and D are incorrect because they lack empathy, fail to acknowledge the client's emotions, or use directive language that may escalate the situation. Choice A focuses on blaming the client, Choice C dismisses the client's feelings, and Choice D is authoritative and may trigger defensiveness.
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)
- A. Impulsive behaviors
- B. Sleeping for long periods of time
- C. Interacting with others in a flirtatious way
- D. Dressing in black or grey clothing
- E. Talking in rapid,continuous speech
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. Impulsive behaviors, interacting flirtatiously, and talking rapidly are classic manifestations of manic behavior in bipolar disorder. Impulsive actions can lead to risky behaviors. Flirtatious interactions are often inappropriate and lack boundaries. Rapid, continuous speech is a hallmark of mania, reflecting racing thoughts and pressured speech. Choices B and D do not align with manic behavior. Sleeping for long periods is more indicative of depression, while dressing in black or grey clothing does not directly correlate with manic episodes.