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A psychiatric nurse is assigned to conduct an admission nursing history on a new client.
- A. What should the admission nursing history for a new psychiatric client include?
- B. The nurse’s opinion regarding the mental and emotional status of the client.
- C. Data addressing the client’s emotional state.
- D. Data that address a biopsychosocial approach, including a family system assessment.
- E. Specific data detailing the client’s mental status.
Correct Answer: C
Rationale: A comprehensive psychiatric nursing history should use a biopsychosocial approach, including physical, psychological, social, and family system assessments, to provide a holistic understanding of the client’s needs. Focusing only on emotional state or mental status is too narrow, and the nurse’s opinion lacks objectivity without assessment data.
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A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?
- A. Vary the interview style for each candidate to learn different techniques
- B. Use simple questions requiring 'yes' and 'no' answers to gain definitive information
- C. Obtain an interview guide from human resources for consistency in interviewing each candidate
- D. Ask personal information of each applicant to assure he/she can meet job demands
Correct Answer: C
Rationale: Obtain an interview guide from human resources for consistency in interviewing each candidate. An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.
The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales?
- A. The nurse believes that the client's symptoms reflect alcohol withdrawal.
- B. The nurse does not know if the client is allergic to this medication.
- C. The nurse knows that the client is not psychotic.
- D. The nurse routinely checks on the doctor's orders.
Correct Answer: A
Rationale: medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take his insulin each day at 1400 hours
- B. Engage in physical activity daily
- C. Increase the amount of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi's effect involves rebound hyperglycemia due to nighttime hypoglycemia. A bedtime snack with protein and carbohydrates prevents hypoglycemia. Options A, B, and C do not directly address this issue.
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
- A. Increase fluid intake to prevent dehydration
- B. Place client on a pressure reducing support surface
- C. Use skin care products designed for use with incontinence
- D. Increase caloric intake to aid healing
Correct Answer: B
Rationale: Place client on a pressure reducing support surface. This prevents skin breakdown due to immobility and reduced sensation.
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
- A. Rotation of injection sites
- B. Insulin mixing and preparation
- C. Daily blood sugar monitoring
- D. Regular high protein diet
Correct Answer: C
Rationale: Daily blood sugar monitoring. Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation indicates elevated glucose levels over time.