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If the older adult's sons and daughters are visiting on the day of the scheduled nurse's visit, which action is most appropriate before beginning the assessment?
- A. Encourage the client's children to offer their comments at any time.
- B. Provide a private setting for conducting the assessment.
- C. Identify the names and relationships of those present.
- D. Offer to share the assessment results with the client's children.
Correct Answer: B
Rationale: A private setting ensures confidentiality and encourages honest responses, critical for an accurate health assessment.
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Which form of instruction is most beneficial when preparing the anxious client?
- A. Provide detailed explanations.
- B. Use short, simple sentences.
- C. Draw elaborate diagrams.
- D. Show a teaching DVD.
Correct Answer: B
Rationale: Short, simple sentences are easier for an anxious client to process, reducing cognitive overload and improving comprehension.
Which of the following instructions are appropriate to include in the teaching plan of a client who is just beginning treatment with imipramine hydrochloride (Tofranil)? Select all that apply.
- A. Avoid tyramine-rich foods such as aged cheese and pickled foods.
- B. Take short naps during the day.
- C. Rise from the chair or bed slowly.
- D. Expect to wait about 3 weeks before feeling better.
- E. Refrain from all sexual activity for 1 month after starting the medication.
- F. Use a good sunscreen when outdoors.
Correct Answer: A,C,D
Rationale: Avoiding tyramine prevents hypertensive crisis, slow rising reduces orthostatic hypotension, and delayed effects set realistic expectations.
彼此The client who abuses marijuana reports liking the drug for its perceived effects. Which experiences if reported by the client should the nurse attribute to marijuana use? Select all that apply.
- A. Euphoria
- B. Increased energy
- C. Sexual enhancement
- D. Appetite suppression
- E. Improved fine-muscle coordination
Correct Answer: A, C
Rationale: Marijuana causes euphoria (A) and enhances sexual experience (C). It causes lethargy (not energy B) increased appetite (not suppression D) and tremors (not coordination E).
What nursing approach is most beneficial for helping the nursing assistant at this time?
- A. Sending the nursing assistant home for the rest of the shift
- B. Terminating the nursing assistant from this type of work
- C. Allowing the nursing assistant to express feelings
- D. Asking the nursing assistant to help with postmortem care
Correct Answer: C
Rationale: Allowing expression of feelings helps the assistant process grief, supporting emotional well-being after a distressing event.
The nurse is interacting with the client who abuses methamphetamine. The client states “I don’t plan to quit meth. I can work for days when I’m high.” Which is the best response by the nurse?
- A. “You’ll exhaust yourself working days when you’re high.”
- B. “You can’t see the real problem yet because you’re in denial.”
- C. “You say you don’t plan to quit. Do you think using drugs helps you?”
- D. “Good point. You probably do work long hours while you are on meth.”
Correct Answer: C
Rationale: Restating neutrally (C) encourages reexamination. Directives (A) labeling denial (B) or agreeing (D) are less effective.