Nokea
The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, 'With my spouse dead, there's no reason for me to go on.' What is the best response by the nurse?
- A. Are you having any thoughts of hurting yourself?'
- B. Do you have any friends in the building?'
- C. Tell me more about how you're feeling.'
- D. You're not thinking of killing yourself, are you?'
Correct Answer: A
Rationale: The client's statement and behavior suggest suicidal ideation. Directly asking about thoughts of self-harm (A) is the most appropriate response to assess risk and ensure safety. Options B, C, and D are less direct and may delay critical intervention.
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The nurse is assisting with the admission of a client who attempted suicide after being diagnosed with end-stage kidney disease. It would be a priority for the nurse to
- A. assign the client a private room near the nurses' station
- B. explore the client's feelings about the diagnosis
- C. initiate continuous one-to-one observation
- D. perform a mental status examination
Correct Answer: C
Rationale: Continuous one-to-one observation (C) is the priority to ensure safety after a suicide attempt. Room assignment (A), exploring feelings (B), and mental status exam (D) are secondary.
The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has the client sip water through a straw. What is the purpose of this action?
- A. To prevent dehydration
- B. To divert the client's attention
- C. To close the epiglottis
- D. To lubricate the tube
Correct Answer: C
Rationale: Sipping water during nasogastric tube insertion triggers swallowing, which closes the epiglottis, preventing the tube from entering the trachea and directing it toward the esophagus.
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.
A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?
- A. My child may experience incontinence.'
- B. My child may seem confused afterwards.'
- C. My child may stare and seem inattentive.'
- D. My child will notice unusual odors prior to the event.'
Correct Answer: C
Rationale: Staring and inattention (C) are hallmark signs of absence seizures. Incontinence (A) and confusion (B) are more typical of other seizures, and odors (D) suggest an aura, not typical in absence seizures.
The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?
- A. Assisting the parents in signing Against Medical Advice (AMA) papers
- B. Discharging the child if parents have power of attorney papers
- C. Notifying the hospital administration about the situation
- D. Reassuring the parents that their decision will be respected under the principle of autonomy
Correct Answer: C
Rationale: A 4-year-old with suspected meningitis requires urgent treatment. Notifying administration (C) ensures legal and ethical intervention to protect the child. AMA (A), power of attorney (B), or respecting autonomy (D) are inappropriate for a minor.