Nokea
A withdrawn, depressed client sits in the day room but refuses to participate in scheduled group activities. When implementing a plan of care the nurse should:
- A. Plan activity that will allow the client to interact with a staff member.
- B. Tell the client that participation in group activities is expected.
- C. Allow the client to select an activity that he can enjoy doing alone.
- D. Ask the client to prepare a list of activities or hobbies he enjoys.
Correct Answer: A
Rationale: One-on-one interaction with a staff member encourages engagement without overwhelming a depressed client. Mandating participation may increase withdrawal. Solitary activities (C, D) do not address social isolation.
You may also like to solve these questions
An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?
- A. I'm sorry you feel that way.'
- B. I went to a fine nursing school.'
- C. You sound upset.'
- D. Please don't speak to me that way.'
Correct Answer: C
Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea.
Based on the nursing assessment, an appropriate priority nursing diagnosis is
- A. risk for constipation related to immobilization.
- B. risk for impaired skin integrity related to immobilization and secretions.
- C. risk for wound infection related to involuntary bowel secretions.
- D. risk for fluid volume excess related to secretions.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) constipation is not a problem because the client has diarrhea (2) correct-skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) there would be risk of fluid volume deficit due to diarrhea and secretions
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
- A. Heart rate
- B. Neurologic status
- C. Urine output
- D. Blood pressure
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.