Nokea
The client states, "It seems strange that I don't have a TV in my room." Which statement would be best for the nurse to provide?
- A. You can watch TV as much as you want outside of your room.
- B. Sometimes clients feel like the TV is sending them messages.
- C. It's important to be out of your room and talking to others.
- D. Watching TV is a passive activity and we want you to be active.
Correct Answer: B
Rationale: The correct answer is B because clients with depression or psychosis may interpret TV as sending messages, so it is often removed to prevent this risk. Choice A is incorrect because it does not address the client's concern and may not be feasible. Choice C is incorrect because it diverts from the client's immediate issue regarding the TV. Choice D is incorrect because it does not address the client's specific concern and instead focuses on the activity level.
You may also like to solve these questions
The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
- A. Short-term memory loss.
- B. Five-pound weight gain.
- C. Decreased affect.
- D. Nausea and vomiting.
Correct Answer: D
Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.
The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?
- A. The client's significant other's statement.
- B. Photographs.
- C. General description.
- D. A summary of the client's feelings.
Correct Answer: B
Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.
The healthcare provider documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here" and tells the healthcare provider that she believes that the television talks to her. The healthcare provider should document these assessment findings in which section of the mental status exam?
- A. Level of concentration
- B. Insight and judgment
- C. Remote memory
- D. Mood and affect
Correct Answer: B
Rationale: Insight and judgment should be documented as these findings assess the client's awareness of their need for treatment and understanding of their condition. In this scenario, the client's statement of not needing to be hospitalized and belief that the television talks to her reflect her insight into her situation and judgment regarding reality. The other options are incorrect: Level of concentration refers to the ability to focus and maintain attention; Remote memory evaluates the recall of past events and information; Mood and affect assess emotional state and expression, which are not directly reflected in the client's statements about her need for hospitalization and belief about the television.
A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
- A. Eat a high-carbohydrate, low-fat, low-protein diet.
- B. Do not take any over-the-counter medication.
- C. Call the crisis hotline if feeling lonely.
- D. Avoid exposure to large crowds.
Correct Answer: B
Rationale: The most important information for the nurse to include in the client's discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.
What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?
- A. National percentile of weight and height.
- B. Frequency of bingeing and purging behaviors.
- C. Perceptions of family and social relationships.
- D. School grades and extracurricular activities.
Correct Answer: B
Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.