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During a home visit, which assessment finding is most suggestive that the client is experiencing auditory hallucinations?
- A. The client sings a song while walking around the room.
- B. The client quickly changes the topic of conversation.
- C. The client repeats a sentence over and over again.
- D. The client turns an ear as if listening to someone.
Correct Answer: D
Rationale: Turning an ear as if listening suggests the client is responding to auditory hallucinations, a common symptom in schizophrenia.
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The client taking disulfiram has a throbbing headache diaphoresis and sudden vomiting. Which possible conclusions by the nurse should be explored first?
- A. The client may have developed influenza.
- B. The client may have recently consumed alcohol.
- C. The client may have recently taken a cough suppressant.
- D. The client may have eaten foods that interact with disulfiram.
Correct Answer: B
Rationale: Alcohol ingestion (B) causes disulfiram reaction (headache diaphoresis vomiting). Influenza (A) cough suppressants (C)
If the nurse documents all of the following information in the database, which finding is probably the most significant source of conflict and anxiety for this client?
- A. The client is facing forced retirement.
- B. The client has 12 grandchildren.
- C. The client is learning to use a computer.
- D. The client wants to sell the family home.
Correct Answer: A
Rationale: Forced retirement is a major life transition that can cause significant stress and anxiety due to loss of role and identity.
Which therapeutic activity is most helpful in facilitating reminiscence therapy among older adult clients?
- A. Discussing a current event topic
- B. Singing popular songs from the 1960s
- C. Reading an article from the newspaper
- D. Making decorations for a future holiday
Correct Answer: B
Rationale: Singing familiar songs from the past stimulates memories, enhancing engagement in reminiscence therapy.
The nurse is teaching home health aides about monitoring for alcohol abuse in older adults. Which response by a home health aide indicates a need for further teaching?
- A. “Alcohol abuse is the largest category of substance abuse problems in older adults.”
- B. “I should monitor more closely for alcohol abuse in single male clients who smoke.”
- C. “Retirement and freedom from work and family pressures tend to decrease alcohol use.”
- D. “Confusion malnutrition and self-neglect may be signs of alcohol abuse in the elderly.”
Correct Answer: C
Rationale: Retirement can increase alcohol use due to isolation (C is incorrect). Alcohol is a major issue (A) risk factors include male smokers (B) and signs include confusion (D).
Which nursing action is most appropriate for determining whether domestic abuse is occurring?
- A. Ask directly if domestic abuse is occurring.
- B. Arrange a second visit to validate suspicions.
- C. Assess the young children for signs of injury.
- D. Make inquiries among relatives or neighbors.
Correct Answer: A
Rationale: Directly asking about abuse in a safe, private setting encourages honest disclosure and is the most effective initial step to confirm suspicions.