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A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?
- A. "I won’t be able to shop for you today because I have to get home to my family."
- B. "I would be happy to do whatever I can to help you."
- C. "What I think you should do is wait for the days when you feel better and do your grocery shopping then."
- D. "Let's look at some other resources to solve this problem."
Correct Answer: D
Rationale: The correct answer is D: "Let's look at some other resources to solve this problem." This response is appropriate because it acknowledges the client's needs while also maintaining professional boundaries. By exploring other resources, such as community services or family support, the nurse can help the client find a more suitable solution.
A: Incorrect. This response is unprofessional and does not address the client's needs.
B: Incorrect. While it shows willingness to help, it does not address the issue of professional boundaries.
C: Incorrect. This response does not offer a practical solution and may not be feasible for the client.
E, F, G: Irrelevant. No information is provided for these options.
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A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Affective flattening.
- B. Bizarre behavior.
- C. Illogicality.
- D. Somatic delusions.
Correct Answer: A
Rationale: The correct answer is A: Affective flattening. Negative symptoms in schizophrenia refer to deficits in normal emotional responses or behaviors. Affective flattening specifically involves a reduction in the expression of emotions, such as reduced facial expressions and tone of voice. This is a core negative symptom in schizophrenia. Bizarre behavior (choice B) is associated with positive symptoms, such as hallucinations and delusions. Illogicality (choice C) is a cognitive symptom related to disorganized thinking. Somatic delusions (choice D) are also positive symptoms involving false beliefs about the body. By process of elimination, Affective flattening is the correct answer.
A nurse is assessing a client experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Increased energy
- C. Increased cognitive awareness
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Chronic stress can lead to the release of stress hormones like cortisol and adrenaline, which can increase blood sugar levels. This occurs due to the body's fight-or-flight response to stress. Hypotension (A) is unlikely as stress typically leads to increased blood pressure. Increased energy (B) is less likely as chronic stress can lead to fatigue and exhaustion. Increased cognitive awareness (C) is not a common finding in chronic stress, as it can impair cognitive function. Hyperglycemia (D) is the most likely finding due to the physiological response to stress.
A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
- A. Provide the client with small meals frequently.
- B. Monitor the client's weight daily.
- C. Allow the client to choose the meals she will eat.
- D. Stay with the client during meals and for 1 hr afterward.
- E. Offer specific privileges for sustained weight gain.
Correct Answer: A, B, D, E
Rationale: The correct actions are A, B, D, and E.
A: Providing small meals frequently helps prevent overwhelming the client and supports gradual weight restoration.
B: Daily weight monitoring is crucial in tracking progress and ensuring the client's safety.
D: Staying with the client during meals and afterward helps prevent purging behaviors and offers support.
E: Offering privileges for sustained weight gain reinforces positive behavior and motivation for recovery.
Incorrect options:
C: Allowing the client to choose meals may lead to restrictive eating habits and hinder weight restoration.
F: No information given.
G: No information given.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Rapid speech
- B. Tics
- C. Distorted perceptual field
- D. Urinary frequency
Correct Answer: A, D
Rationale: Moderate anxiety is associated with physical restlessness, rapid speech, and increased urinary frequency.
Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.