Nokea
A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?
- A. She is in an early stage of normal grief.
- B. She may be hallucinating.
- C. She may be having illusions.
- D. She may be in a severe depression.
Correct Answer: A
Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.
You may also like to solve these questions
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a rash to my doctor.
- B. I should take this medication at the same time each day.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping lamotrigine when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: rash may indicate Stevens-Johnson syndrome, consistent timing ensures steady levels, and alcohol increases sedation.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
- A. This Test is performed by sticking my finger and measuring the results.
- B. This Test needs to be performed in the morning before I eat breakfast.
- C. This Test indicates how well my blood sugar has been controlled the past 6-8 weeks.
- D. I must follow my diet carefully for several days before the Test .
Correct Answer: C
Rationale: when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: Transferring into and out of a wheelchair is essential for a paraplegic to perform ADLs independently, enabling mobility and access to other tasks. Shaving, maneuvering the wheelchair, and cooking are important but less critical if transfer ability is impaired.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units before meals. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and confusion.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and confusion indicate hypoglycemia, a medical emergency with insulin lispro. Options A, C, and D are less urgent.