Nokea
A primigravida client who came to the clinic has been diagnosed with a urinary tract infection. She repeatedly verbalizes concern regarding the safety of the fetus. Which should the nurse address first?
- A. Maternal and infant safety
- B. Obtaining a sedative prescription
- C. Instructions regarding improved hygiene
- D. Instructions regarding medication compliance
Correct Answer: A
Rationale: The primary concern of this client is the safety of her fetus rather than herself. The priority for the nurse to address at this time is the issues regarding safety. The remaining options lack this priority.
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The nurse discovers a hospice client has expired. The family members are assembled in the facility's waiting room. Which of the following statements by the nurse would be the most appropriate?
- A. My condolences on the passing of your family member. You may visit him if you wish.
- B. I will give you some time to spend with your loved one. Let me know if you need anything.
- C. You should view your loved one as a way of saying farewell.
- D. It would be best if you not view your loved one just yet.
Correct Answer: B
Rationale: This statement offers support, gives the family autonomy, and invites further communication, which is sensitive and appropriate.
A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
- A. Ongoing fluid restriction
- B. The need for genetic counseling
- C. The risk of hypotensive episodes
- D. Depression regarding massive edema
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
A young female client hospitalized on the inpatient psychiatric unit receives treatment for anorexia nervosa. Which statement made by the client to the nurse best indicates improvement?
- A. The client states, 'I realize I am too thin and that it is not good for me, but I do not know how to eat more without getting fat.'
- B. The client requests a sanitary pad, saying, 'I did not think to bring anything with me. I have not had a period for months.'
- C. The client states, 'Either the food here is getting better or my appetite is coming back, but lately I find myself looking forward to meals.'
- D. The client asks for her discharge date to be delayed and says, 'I do not feel ready yet to deal with the tension in my family and their demands for perfection.'
Correct Answer: C
Rationale: Looking forward to meals indicates improved appetite and a positive shift in attitude toward eating, a key sign of progress in anorexia treatment. Other statements reflect awareness, physical changes, or anxiety, but do not directly indicate improved eating behavior.
The nurse is caring for a client diagnosed with bipolar disorder. During the morning assessment, the client tells the nurse that she hears people in the room behind her bed talking about her. Which response by the nurse best reflects therapeutic communication?
- A. What do you hear them saying?
- B. I will see if we can move you to another room.
- C. I will notify your doctor in case he wants to change your medications.
- D. I understand that the voices seem real to you, but I don't see or hear anyone else in here.
Correct Answer: D
Rationale: This response validates the client's experience without reinforcing the hallucination and promotes trust by acknowledging their perception.
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.