Nokea
The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct Answer: B
Rationale: Step 1: Initiating short, frequent contacts with the client will promote trust by establishing a consistent and supportive presence.
Step 2: This approach allows the nurse to build rapport and demonstrate genuine concern for the client's well-being.
Step 3: Regular interactions can help the client feel understood and supported, leading to a more trusting relationship.
Step 4: By maintaining frequent contact, the nurse can monitor the client's well-being and provide reassurance as needed.
Step 5: This proactive approach fosters trust and a therapeutic alliance, enhancing the client's overall care experience.
You may also like to solve these questions
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate.
Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.
A client with newly diagnosed hypertension is prescribed enalapril (Vasotec). Which instruction should the nurse provide to the client?
- A. Increase your intake of potassium-rich foods.
- B. Report any persistent cough to your healthcare provider.
- C. Take the medication with a full meal.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: Report any persistent cough to your healthcare provider. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a side effect. This cough can be a sign of a serious condition called angioedema. Therefore, it is crucial for the client to report any cough to their healthcare provider promptly to assess and manage it.
Incorrect choices:
A: Increasing intake of potassium-rich foods is not necessary when taking enalapril, as it does not typically cause potassium imbalances.
C: Enalapril can be taken with or without food, so taking it with a full meal is not a specific instruction.
D: Avoiding grapefruit juice is typically recommended for medications metabolized by the CYP3A4 enzyme, which enalapril is not.
A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?
- A. Administer morphine sulfate.
- B. Place the client in a high Fowler's position.
- C. Initiate continuous ECG monitoring.
- D. Prepare the client for intubation.
Correct Answer: B
Rationale: The correct action for the nurse to take first is to place the client in a high Fowler's position (Choice B). This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and improving ventilation. With severe shortness of breath and pink, frothy sputum, the priority is to optimize respiratory function. Administering morphine sulfate (Choice A) may be indicated later for pain and anxiety but is not the immediate priority. Initiating continuous ECG monitoring (Choice C) is important but not as urgent as addressing the respiratory distress. Preparing the client for intubation (Choice D) should be considered if respiratory distress worsens, but initial interventions should focus on improving oxygenation through positioning.
A client with a history of myocardial infarction (MI) is prescribed atorvastatin (Lipitor). Which outcome indicates that the medication is effective?
- A. Increased blood pressure.
- B. Lowered cholesterol levels.
- C. Decreased heart rate.
- D. Improved liver function.
Correct Answer: B
Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a statin medication used to lower cholesterol levels, reducing the risk of further cardiovascular events in patients with a history of MI. Lowering cholesterol helps prevent plaque buildup in arteries, reducing the likelihood of another MI. Increased blood pressure (A) and decreased heart rate (C) are not direct indicators of atorvastatin's effectiveness. Improved liver function (D) may be a consideration due to potential side effects, but the primary goal of atorvastatin is to lower cholesterol levels to prevent cardiovascular events.
The healthcare provider is caring for a patient who is taking warfarin (Coumadin). Which laboratory value should the healthcare provider monitor closely?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Hemoglobin level.
- D. White blood cell count.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT). Warfarin is an anticoagulant medication that works by inhibiting clotting factors. Monitoring PT is essential to ensure the patient's blood is clotting within the desired range to prevent both bleeding and clotting events. Platelet count (A) assesses the quantity of platelets, not the clotting function. Hemoglobin level (C) evaluates red blood cell count and oxygen-carrying capacity. White blood cell count (D) assesses immune function and infection risk, not clotting ability. PT is directly related to warfarin's mechanism of action, making it the most crucial parameter to monitor.