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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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The client is receiving clonidine to relieve selected symptoms of opioid withdrawal. Which assessment is most important for the nurse to complete before administering clonidine?
- A. Check for presence of dilated pupils
- B. Investigate recent nausea or vomiting
- C. Test for abnormally heightened reflexes
- D. Verify that the blood pressure is not low
Correct Answer: D
Rationale: Clonidine requires BP check (D) to avoid hypotension. Dilated pupils (A) nausea (B) and reflexes (C) don’t contraindicate it.
The nurse is caring for the client who was violently raped 3 months ago and has a diagnosis of rape-trauma syndrome. Which assessment findings associated with rape-trauma syndrome should the nurse anticipate? Select all that apply.
- A. Anorexia
- B. Nightmares
- C. Hypertension
- D. Fears and phobias
- E. Sexual promiscuity
Correct Answer: A ,B, D
Rationale: Rape-trauma syndrome symptoms include physiological symptoms such as loss of appetite (A) nightmares of the attack occurring again (B) and fears and phobias (D) due to feelings of vulnerability. Hypertension (C) is not a recognized symptom and fear of sexual encounters not promiscuity (E) is typical.
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
When a 24-year-old with a record of multiple convictions for driving under the influence (DUI) claims not to be an alcoholic, which is the most pertinent assessment question the nurse can ask?
- A. When you drink, do you drink beer or hard liquor?
- B. Did you begin drinking before or after you were of legal age?
- C. Do you prefer to drink alcohol rather than soft drinks?
- D. Are you unable to recall events that occurred while drinking?
Correct Answer: D
Rationale: Asking about memory loss during drinking episodes assesses for blackouts, a key indicator of problematic drinking patterns associated with alcoholism.
Which information is most appropriate for the nurse to tell the client about taking alprazolam (Xanax)?
- A. Avoid consuming alcohol while taking this drug.
- B. Take the medication with a full meal.
- C. This drug can cause insomnia in some people.
- D. A blood test will be required periodically.
Correct Answer: A
Rationale: Alcohol potentiates alprazolam's sedative effects, increasing the risk of respiratory depression and overdose, making this a critical instruction.