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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The client expresses ambivalence about quitting smoking and also the fear of “getting fat” and “looking like a cow.” The client wonders if that is worse than smoking. Which response by the nurse is most helpful?
- A. “We could set up a diet for you to start at the same time to prevent you from gaining any weight.”
- B. “Don’t you think it would be much better to breathe more easily even if you gain a little weight?”
- C. “You don’t want to quit smoking because you think you might gain weight. Do you see yourself as overweight?”
- D. “It sounds like you are afraid of weight gain. Tell me about the good and bad things that might happen if you give up smoking.”
Correct Answer: D
Rationale: Acknowledging weight gain fear and exploring pros/cons (D) aids decision-making. Dieting (A) risks relapse health focus (B) dismisses fear closed question (C) limits discussion.
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.
When debriefing the unit’s staff after the client’s catastrophic reaction the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?
- A. The client’s safety is at jeopardy if the staff is feeling threatened.
- B. An agitated staff will not be able to manage the situation as effectively.
- C. The client will sense the staff’s agitation and aggressive behavior will escalate.
- D. An agitated staff response is indicative of a need for additional crisis-control training.
Correct Answer: C
Rationale: Staff agitation escalates client aggression (C). Safety (A) management (B) and training (D) are secondary concerns.
Which assessment finding by the nurse is most suggestive to the obese client is taking dextroamphetamine (Dexedrine) at this time?
- A. The client stares blankly into space.
- B. The client monopolizes the discussions.
- C. The client wears sunglasses indoors.
- D. The client slurs words when speaking.
Correct Answer: B
Rationale: Monopolizing discussions reflects the hyperactivity and talkativeness associated with stimulant use like dextroamphetamine.
The NA is helping the ED nurse admit a woman who is the victim of spousal abuse and marital rape. The NA asks the nurse what should be done with the woman’s torn and soiled clothing. What is the nurse’s best response?
- A. “Place items in a plastic bag and avoid blood and body fluid contact.”
- B. “Ask the woman what she wants done with her clothing; she may want them discarded.”
- C. “These may be needed by the police. I will remove them and place in separate paper bags.”
- D. “Fold each article of clothing and leave them with her; she can decide later about disposal.”
Correct Answer: C
Rationale: Placing clothing in paper bags (C) preserves evidence for police. Plastic bags (A) cause mold asking the victim (B) or leaving with her (D) risks evidence loss.