Nokea
An adult is admitted to the psychiatric unit with a severe phobia. She develops severe anxiety when she crosses any type of bridge. She can no longer go to work or go shopping at the mall. The day after admission, she develops a panic attack and refuses to go to occupational therapy because she has to cross a bridge-like structure to go from one area of the hospital to another. How should the nurse respond to this situation?
- A. Accompany the client as she goes to occupational therapy
- B. Request that she be excused from occupational therapy until she is less anxious
- C. Have a staff member walk her to occupational therapy by a different route that does not cross a bridge-like structure
- D. Tell her that facing her fears is the only way to conquer them and that the nurse will help her do that
Correct Answer: C
Rationale: Using an alternate route avoids triggering the phobia, allowing participation in therapy while respecting her current anxiety level.
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A client has been on antibiotics for 72 hours for cystitis.
Which report from the client requires priority attention by the nurse?
- A. Dysuria
- B. Body malaise
- C. Rashes all over the body and slight breathing problems.
- D. Poor appetite.
Correct Answer: C
Rationale: Rashes and breathing problems are signs of a delayed allergic reaction to antibiotics, requiring urgent attention.
A client is being admitted with a diagnosis of possible pancreatitis. Which of the following is the best support for this diagnosis?
- A. Pain is in the left upper quadrant of the abdomen
- B. Client reports steatorrhea for the last 3 days
- C. A serum amylase level of 366 U/L
- D. Assessed diminished bowel sounds
Correct Answer: C
Rationale: The client's amylase level is elevated above the normal level of 200 U/L. This measurement is the most accurate indicator of pancreatitis and the most objective and specific. The answers in A, B, and D are also clinical manifestations of pancreatitis, but are not as specific as the laboratory value, so they are incorrect choices.
Mr. Smith is 67-year-old black male brought to the hospital by his wife, who stated that he fell down 20 minutes ago and has been unable to speak or move his right side since then, Mr. Smith has no significant past medical history. On exam, Mr. Smith is conscious, very anxious, his speech is garbed and unintelligible, he has a left facial droop, and he is completely right hemiphlegic.
The most likely etiology for his symptoms is:
- A. CVA
- B. Traumatic brain injury
- C. Brain tumor
- D. Alzheimer's disease
Correct Answer: A
Rationale: Symptoms of sudden speech loss, facial droop, and hemiplegia strongly suggest a cerebrovascular accident (stroke).
An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client?
- A. Restrain her so she will not wander in the halls
- B. Ask her roommate to call the nurse whenever she leaves the room
- C. Punish her when she gets in a bed other than her own
- D. Put her favorite picture on the door to her room
Correct Answer: D
Rationale: A familiar picture on the door helps the Alzheimer's client recognize her room, reducing wandering safely. Restraints, roommate monitoring, or punishment are inappropriate or ineffective.
A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?
- A. Unlicensed assistive personnel (UAP)
- B. Senior nursing student
- C. PN
- D. RN
Correct Answer: D
Rationale: The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed.