Nokea
If the home health nurse documented all of the following findings, which one is most suggestive that the client is depressed?
- A. The client is irritable after grandchildren visit.
- B. The client has multiple, unrelated physical complaints.
- C. The client takes lengthy naps in the late afternoon.
- D. The client cries when talking about a dead spouse.
Correct Answer: B
Rationale: Multiple somatic complaints are a hallmark of depression in older adults, often masking emotional symptoms.
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The spouse of the client who is currently in inpatient treatment for substance abuse tells the nurse “We’ve done this so many times. I don’t think my spouse is ever going to change. Do you think it’s time for me to get a divorce?” Which response by the nurse is most helpful?
- A. “You don’t think your spouse is ever going to change?”
- B. “Sounds like you’re feeling discouraged in your marriage.”
- C. “Your spouse will likely continue to use and need treatment again.”
- D. “That’s your decision; I can’t tell you whether you should get a divorce.”
Correct Answer: B
Rationale: Validating discouragement (B) encourages exploration. Restatement (A) is less effective predicting relapse (C) is opinionated and dismissing (D) closes communication.
The nurse manager concerned about the potential for staff harm on a behavioral health unit is assessing the unit’s milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence?
- A. Two clients have a history of spousal abuse.
- B. Several clients have lost smoking privileges.
- C. The unit is currently at less than full client capacity.
- D. The nurse from a medical unit is assigned to work on the unit.
Correct Answer: D
Rationale: Staff inexperience (D) predicts violence. Client history (A) and privileges (B) are client-focused and low capacity (C) reduces not increases risk.
Which action by the client is most suggestive of denial about the illness?
- A. The client conceals the information from family members.
- B. The client avoids contact with homosexual friends.
- C. The client responds to the former group of the nurse.
- D. The client has intercourse without using condoms.
Correct Answer: D
Rationale: Engaging in unprotected intercourse indicates denial of the HIV diagnosis, as it disregards the risk of transmission and personal health implications.
Which response by the nurse is most accurate?
- A. It will show up in urine tests 3 to 4 days after use.
- B. Traces may be picked up by sensitive blood tests 8 to 10 weeks later.
- C. Hair analysis can detect marijuana use more than a year before the urine test.
- D. Marijuana leaves the body within 2 hours of smoking it.
Correct Answer: B
Rationale: Marijuana metabolites can be detected in blood tests for weeks, with sensitive tests picking up traces 8 to 10 weeks after use, depending on frequency and amount used.
The nurse is preparing to administer chlordiazepoxide 75 mg orally for the client experiencing severe withdrawal symptoms due to alprazolam dependency. The medication is supplied in 25-mg capsules. How many capsules should the nurse prepare to administer?_ capsule(s) (Record your answer as a whole number.)
Correct Answer: 3
Rationale: Proportion: 25 mg/1 capsule = 75 mg/X capsules; 25X = 75; X = 3 capsules.