Nokea
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Assist the client with relaxation techniques in the group.
- B. Escort the client from the group to reduce stimuli.
- C. Provide education about ways to cope with anxiety.
- D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A
Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.
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A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Teach the client to develop a plan for daily structured activities.
- B. Encourage the client to exercise.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Provide education on methods to enhance sleep.
Correct Answer: A
Rationale: Structured daily activities provide purpose and combat psychomotor retardation and lack of motivation, key to restoring function.
The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap is too harsh for the radiation site, indicating a need for further teaching. Prescribed lotions, protective clothing, and patting to dry are appropriate.
History and Physical
Laboratory Results
Imaging Studies
Initial vital signs
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room and another set of vital signs is performed. Physician notified and orders received.
Select the client actions that were effective in her treatment.
- A. Denies cramps, weakness, or nausea
- B. BP 116/68 mm Hg, HR 75 bpm
- C. Potassium level 3.6 mEq/L (3.6 mmol/L)
- D. Verbalizes commitment to dialysis appointments
- E. Client states that she will need to resume her Lisinopril to control blood pressure
- F. The client is eager to add dark green vegetables and potatoes to her diet
Correct Answer: B,C,D
Rationale: Stable BP/HR, normal potassium, and dialysis commitment indicate effective treatment. Denying symptoms needs investigation, resuming Lisinopril requires provider guidance, and high-potassium foods are inappropriate.
A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should be aware of the signs and symptoms of his illness.
- B. The client should plan to participate in group or individual therapy while at college.
- C. Despite the illness, the client should be able to live away from home.
- D. The client's serum lithium levels should be routinely evaluated.
Correct Answer: D
Rationale: Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity, especially critical for a newly diagnosed client transitioning to college.
The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
- A. Encourage the mother to write thoughts and feelings in a journal.
- B. Determine if the mother has other children who do not have developmental disabilities.
- C. Reassure the mother that her child will achieve some growth and development milestones.
- D. Ask the mother if she has ever thought about harming herself or her child.
Correct Answer: D
Rationale: Asking about thoughts of self-harm or harm to the child assesses the severity of depression and risk, a critical first step. [Note: Document incorrectly lists A; D is more appropriate for safety.]