Nokea
An adolescent client has been hospitalized for 2 months for an eating disorder. She asks the nurse what to tell her classmates about her long absence. The nurse can best help the client by:
- A. Having her practice changing the subject when asked personal questions
- B. Helping her invent a believable explanation for her absence
- C. Engaging her in role playing activities that are likely to occur
- D. Encouraging her to share her experiences with those who ask
Correct Answer: C
Rationale: Role-playing helps the client prepare for social interactions, building confidence in handling questions about her absence.
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The nurse is caring for a client with bipolar disorder who is hospitalized for an acute manic episode. Which of the following actions would the nurse expect to be included in the client's plan of care? Select all that apply.
- A. Ask the client to plan an outing for the unit
- B. Assign the client to a private room
- C. Assist client in choosing appropriate clothing
- D. Include the client in group therapy sessions
- E. Schedule the client for physical activity with a staff member
- F. Seat the client with other clients in the dining room for meals
Correct Answer: B,C,D,E,F
Rationale: During a manic episode, a private room (B) minimizes stimuli, appropriate clothing (C) supports dignity, group therapy (D) fosters socialization, physical activity (E) channels energy, and dining with others (F) promotes normalcy. Planning an outing (A) is inappropriate due to impulsivity risks.
The nurse is planning care for a client who must remain in bed for several weeks. Which action will do most to prevent the development of pressure ulcers?
- A. Performing range-of-motion exercises
- B. Deep breathing and coughing
- C. Keeping the feet against a footboard
- D. Changing position in bed frequently
Correct Answer: D
Rationale: Frequent position changes relieve pressure on bony prominences, preventing pressure ulcers. ROM, breathing, or footboards address other complications.
The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.