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A terminally ill client says to the nurse, 'Do you believe in heaven?' How should the nurse respond?
- A. Yes, I believe in heaven and hell.'
- B. My personal belief is private.'
- C. Do you believe in heaven?'
- D. Do you want to see your clergyman?'
Correct Answer: C
Rationale: Reflecting the question back encourages the client to share beliefs, fostering spiritual discussion. Sharing personal beliefs, withholding, or redirecting are less therapeutic.
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The nurse knows which of the following would be MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment?
- A. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups.
- B. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking.
- C. Tell the family that it is not their fault that the client behaves inappropriately.
- D. Involve the family in the assessment of the client when s/he is first admitted to the hospital.
Correct Answer: A
Rationale: The Alliance for the Mentally Ill offers ongoing education and support groups, equipping families with skills to manage behaviors long-term. Pamphlets, reassurance, and early involvement are helpful but lack the sustained impact of a support network.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
- A. Which intervention should the nurse include in the care plan for a client with COPD?
- B. Encourage a high-protein, low-carbohydrate diet.
- C. Administer oxygen at 6 liters per minute via nasal cannula.
- D. Teach the client to use pursed-lip breathing.
- E. Place the client in a supine position to promote rest.
Correct Answer: C
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and improving oxygenation in COPD. High-protein diets are beneficial but secondary, high-flow oxygen risks CO2 retention, and supine positioning impairs breathing.
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Weight gain of 5 pounds in a month.
- C. Occasional joint stiffness.
- D. Mild headache.
Correct Answer: B
Rationale: Weight gain of 5 pounds in a month suggests prednisone-induced fluid retention, requiring evaluation. Options A, C, and D are less urgent.
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying 'no' and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- A. Trust
- B. Initiative
- C. Independence
- D. Self-esteem
Correct Answer: C
Rationale: Independence. In Erikson's theory of development, toddlers struggle to assert independence, often using the word 'no' to establish autonomy.