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The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate?
- A. Prepare a schedule of activities and monitor the client's participation in the activities.
- B. Encourage the client to choose the client's own activities.
- C. Allow the client time to get acclimated to the milieu before scheduling activities.
- D. Allow the client to rest quietly to restore energy level.
Correct Answer: C
Rationale: Allowing time to acclimate helps the client adjust to the new environment, reducing stress and supporting engagement, especially given their cognitive and social challenges. Scheduling activities or encouraging choices may be premature, and rest alone does not address isolation.
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The nurse is caring for a client who has been diagnosed with terminal pancreatic cancer. The family is asking what to expect when the end draws near. Which response by the nurse is most appropriate?
- A. I will have the doctor talk to you about that.
- B. The hospice nurse is the best person to answer your questions. I can put in a consult for you.
- C. Don't worry about that right now. You don't know if there is another treatment option that will work.
- D. I can tell you what to look for when the time comes. In the meantime, what are your wishes and goals for care?
Correct Answer: D
Rationale: This response addresses the family's question while opening a discussion about care goals, which is supportive and appropriate.
A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client?
- A. Assign the client a new task to master.
- B. Turn on the television to a musical program.
- C. Make the client aware that the behavior is undesirable.
- D. Talk about the family pictures on display in the client's room.
Correct Answer: D
Rationale: Providing familiar objects will decrease anxiety. Decreasing environmental stimuli also aids in reducing agitation for the head-injured client. Option 1 does not simplify the environment because a new task may be frustrating. Option 2 increases stimuli. In option 3 the nurse uses negative reinforcement to help the client adjust.
A client diagnosed with catatonic schizophrenia demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. Which intervention by the nurse is most appropriate to increase interpersonal communication?
- A. Ask the client direct questions to encourage talking.
- B. Leave the client alone and intermittently check on her or him.
- C. Sit beside the client in silence and occasionally ask open-ended questions.
- D. Take the client into the dayroom with the other clients, to encourage interaction.
Correct Answer: C
Rationale: Clients who are withdrawn may be immobile and mute, and they require consistent, repeated approaches. Intervention includes the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. Asking this client direct questions is not therapeutic. The client is not to be left alone. This client is not capable of interaction in the dayroom.
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
- A. Monitor vital signs every 15 minutes.
- B. Administer bromocriptine as prescribed.
- C. Administer the haloperidol as prescribed.
- D. Assess the client's level of consciousness.
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
- A. Risk of tachycardia
- B. Probability of fatigue
- C. High incidence of hypoglycemia
- D. Possible exacerbation of depression
Correct Answer: D
Rationale: Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia rather than tachycardia. Fatigue is a possible side effect, but it is not the most important item. Hypoglycemia is a sign that is masked with beta blockers.