Nokea
A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. I haven't gotten my period yet, and all my friends have theirs.
- B. There's a big pimple on my face, and I worry that everyone will notice it.
- C. My parents treat me like a baby sometimes.
- D. None of the kids at this school like me, and I don't like them either.
Correct Answer: D
Rationale: The correct answer is D because the adolescent's statement indicates feelings of social isolation and potential difficulty in forming relationships with peers. Addressing this issue is crucial to prevent further emotional distress. Choice A is common for adolescents and does not raise immediate concerns. Choice B is a common concern related to body image. Choice C may indicate normal parent-child dynamics.
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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.
A nurse is planning care for a client who has hyperthyroidism and is receiving radioactive iodine (radioiodine). Which of the following statements by the nurse regarding special precautions is appropriate?
- A. You will need to use a bathroom separate from other household members.
- B. You will need to remain at the hospital for the entire time the radioiodine is radioactive.
- C. A low fiber diet will be necessary.
- D. Additional Immunizations will be needed for full protection.
Correct Answer: A
Rationale: Rationale: Choice A is correct because radioiodine is excreted through bodily fluids including urine. Using a separate bathroom prevents exposure to others. Choice B is incorrect as hospitalization isn't always required. Choice C is irrelevant to radioiodine therapy. Choice D is incorrect as immunizations are not directly related to radioiodine precautions.
A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Bizarre behavior
- B. Waxy flexibility
- C. Somatic delusions
- D. Illogicality
Correct Answer: B
Rationale: Waxy flexibility reflects a lack of normal movement a negative symptom of schizophrenia.
A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?
- A. Let's discuss what you mean when you say that you cannot ever return to work.
- B. You need to work hard on resolving conflict with those closest to you.
- C. Antidepressants are not your solution, but this therapy group is.
- D. I notice you keep clenching your fists. Why are you doing this?
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A demonstrates active listening and encourages further exploration of the client's feelings and perspectives. It shows empathy and promotes open communication. It allows the nurse to understand the client's concerns about returning to work and address them effectively.
Summary:
B: This choice is not appropriate as it focuses on resolving interpersonal conflicts rather than addressing the client's concerns about their diagnosis.
C: This choice dismisses the potential need for medication and minimizes the importance of therapeutic support.
D: This choice addresses a physical behavior without directly addressing the client's emotional concerns about work.
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.