Nokea
If the client's pain is the result of a panic attack, which findings will the nurse most likely note during the physical assessment? Select all that apply.
- A. Tachycardia
- B. Hypotension
- C. Increased salivation
- D. Constricted pupils
- E. Sweating
- F. Unsteady gait
Correct Answer: A,E
Rationale: Panic attacks typically cause tachycardia and sweating due to sympathetic nervous system activation, reflecting acute anxiety.
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Which nursing intervention is most beneficial for the client's spouse at this time?
- A. Suggesting that the spouse make an appointment for a physical examination
- B. Discussing modifying the amount of time the spouse devotes to care-giving
- C. Reminding the spouse of the scheduled times for visiting clients on the unit
- D. Explaining that many staff are available to care for the client
Correct Answer: B
Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.
The client often avoids talking about cocaine use by refocusing on other problems such as losing a job and family discord. Which is the most helpful response by the nurse when the client avoids discussing using cocaine?
- A. “Has your cocaine use helped you to cope with these problems in the past?”
- B. “You need to consider that all these problems are related to your cocaine use.”
- C. “How do you think these problems will change once you no longer use cocaine?”
- D. “You can’t do anything about these while here. Just focus on getting off of cocaine.”
Correct Answer: C
Rationale: Linking drug use to problems (C) builds insight. Coping (A) is inaccurate opinions (B) cause defensiveness and avoiding issues (D) is unhelpful.
The client who recently emigrated from Iran is on the mental health unit and has been placed in seclusion. The nurse assesses that the client is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity?
- A. Gives the client a thumbs-up gesture
- B. Avoids looking at the clock or a watch
- C. Has the NA bring the client a cup of tea
- D. Offers to bring the client the book of Quran
Correct Answer: A
Rationale: A thumbs-up (A) is offensive in Iranian culture akin to a vulgar gesture. Avoiding clocks (B) offering tea (C) and providing the Quran (D) are culturally appropriate.
The 19-year-old is given a court order to enter treatment for cocaine abuse. The client threatens to leave the treatment facility AMA. Which statement by the nurse demonstrates an accurate understanding of the client’s options?
- A. “The client is of legal age and can leave on his own will; we can’t stop him from leaving.”
- B. “Due to the court order the client is not allowed to leave and will be placed in seclusion.”
- C. “The client is allowed to leave as long as the court is informed; I’ll prepare the documents.”
- D. “The client cannot leave and will be returned to treatment or another option by court order.”
Correct Answer: D
Rationale: Court-ordered clients cannot leave voluntarily (D). Age (A) is irrelevant seclusion (B) is illegal informing court (C) doesn’t allow leaving.
What suggestion can the nurse make if the client complains of feeling dizzy when taking doxepin (Sinequan) at bedtime as prescribed?
- A. Place a cool compress on your forehead.
- B. Get up slowly from a seated position.
- C. Remain in bed with your feet elevated above your heart.
- D. Take some deep breaths before getting out of bed.
Correct Answer: B
Rationale: Rising slowly minimizes orthostatic hypotension, a common side effect of doxepin, reducing dizziness.