Nokea
On the basis of this change in the client's condition, which nursing action is most appropriate to perform next?
- A. Identifying the client's religious preference
- B. Calling the nursing supervisor
- C. Notifying the physician
- D. Documenting the assessed data in the client's chart
Correct Answer: C
Rationale: Notifying the physician promptly addresses the acute change (delirium tremens), ensuring rapid intervention for a potentially life-threatening condition.
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The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?
- A. Alert other staff to the client’s apparent escalation.
- B. Ask why the client is overreacting to the situation.
- C. Leave the room until the client has regained control.
- D. Apologize to the client for being late with the treatment.
Correct Answer: D
Rationale: Apologizing (D) validates the client’s distress and acknowledges the nurse’s role de-escalating the situation. Alerting staff (A) is secondary asking why (B) may escalate defensiveness and leaving (C) avoids communication.
The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma. What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?
- A. The client’s ability to process information including instructions is limited.
- B. The client has a decreased ability to interpret and tolerate sensory stimuli.
- C. The staff has a more difficult time providing appropriate milieu boundaries.
- D. The staff’s attention is oftentimes diverted to other more manipulative clients.
Correct Answer: B
Rationale: Decreased ability to tolerate sensory stimuli (B) triggers catastrophic reactions. Processing (A) boundaries (C) and staff attention (D) are not primary contributors.
The nurse is conducting an admission history on the client being hospitalized with symptoms characteristic of schizophrenia. Which interview question demonstrates that the nurse can identify the most prevalent comorbid substance abuse issue for the client with schizophrenia?
- A. “When did you last smoke or use marijuana?”
- B. “Did you bring any street drugs to the hospital?”
- C. “How much alcohol do you drink in a 24-hour period?”
- D. “Did you give the nursing assistant all your cigarettes and lighters?”
Correct Answer: D
Rationale: Nicotine use (D) is most prevalent (70-90%) in schizophrenia. Marijuana (A) street drugs (B) and alcohol (C) are less common.
If the client admits that incidences of domestic abuse are occurring, which nursing intervention is most beneficial?
- A. Offering the victim money to leave home
- B. Identifying resources for shelter and safety
- C. Recommending termination of the abusive relationship
- D. Suggesting joint counseling with a therapist or clergyman
Correct Answer: B
Rationale: Providing resources for shelter and safety ensures the victim's immediate protection and access to support, addressing the urgent need for security.
If the rape victim shares all of the following information during a group session, which findings are most indicative of a severe adjustment reaction? Select all that apply.
- A. The victim reports feeling somewhat anxious.
- B. The victim describes having sporadic nightmares.
- C. The victim has lost weight and eats out of habit.
- D. The victim has occasional doubts about self-worth.
- E. The victim refuses to have sexual relations.
- F. The victim has started to drink wine before bedtime.
Correct Answer: B,C,E,F
Rationale: Nightmares, weight loss, sexual avoidance, and new alcohol use indicate significant distress and maladaptive coping, suggestive of a severe adjustment reaction.