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If the client has been taking an antidepressant for several weeks, which outcome would be the most desired therapeutic effect?
- A. The client is feeling less depressed.
- B. The client is eating more nutritiously.
- C. The client is having fewer food binges.
- D. The client is feeling less suicidal.
Correct Answer: C
Rationale: Reducing binge episodes is the primary goal for bulimia treatment, as antidepressants target the compulsive behaviors associated with the disorder.
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The nurse is developing the answer key to a post test that will be given to participants following a workshop about caffeine abuse among older adult clients. Which statement about caffeine abuse should be excluded from the answer key?
- A. Caffeine withdrawal symptoms include headache fatigue and depression.
- B. Caffeine withdrawal is a medical diagnosis and treatment can be provided.
- C. Caffeine abuse causes hypoglycemia tachycardia and decreased lipid levels.
- D. Caffeine withdrawal symptoms begin 12-24 hours after discontinuing its use.
Correct Answer: C
Rationale: Caffeine causes hyperglycemia tachycardia and increased lipids (C is false). Withdrawal symptoms (A D) and diagnosis (B) are correct.
The client with Alzheimer’s disease becomes increasingly agitated and states “I must go and clean out the barn!” Which nursing response is most therapeutic?
- A. “What makes you think that the barn needs to be cleaned?”
- B. “So you’ve cleaned a barn. Tell me did you live on a farm?”
- C. “It’s awfully hot today; maybe you should wait until tomorrow.”
- D. “There are no barns around here. Would you like something to eat?”
Correct Answer: B
Rationale: Redirecting to memories (B) calms agitation without confrontation. Asking why (A) or stating facts (D) may escalate and delaying (C) blocks communication.
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 client is being admitted to the ICU with drug overdose that resulted in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and is kicking shoving throwing items in the room and threatening staff. The charge nurse calls a behavioral situation code and 4-point restraints are applied by the team. Which intervention is most important for the nurse to implement next?
- A. Have staff members who were harmed complete an incident report.
- B. Contact the health care provider to obtain an order for restraint use.
- C. Document the client’s behavior and action taken in the nurse’s notes.
- D. Check that the client’s wrist restraints are tightly secured to the HOB.
Correct Answer: B
Rationale: A physician or licensed independent practitioner must prescribe restraints and assess the client within 1 hour of restraint placement for client and staff safety. Incident reports (A) follow treatment documentation (C) follows HCP contact and securing restraints to the HOB (D) risks circulation impairment.
Which question during the client interview is likely to generate the most information?
- A. Tell me about your family.
- B. Are you currently married?
- C. Who is your nearest relative?
- D. Give me a list of your family members.
Correct Answer: A
Rationale: An open-ended question about family prompts detailed responses, providing comprehensive insight into social support and history.