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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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A client is admitted to the psychiatric unit with a diagnosis of schizophrenia. The client verbalizes to the nurse, 'Someone wants to kill me tonight.' Which response by the nurse is best?
- A. No one wants to kill you.
- B. Why do you think that?
- C. They don't know you are hospitalized, so you are safe.
- D. It must feel frightening to think someone wants to hurt you.
Correct Answer: D
Rationale: Acknowledging the client’s fear validates their emotions and builds trust without reinforcing delusions. Denying the belief, questioning, or reassuring about safety may escalate agitation or distrust in a client with schizophrenia.
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. help the client bathe and change into fresh clothing before the examination begins
- B. preserve any evidence, including clothing, and take photographs of injuries as appropriate
- C. assure the client that surviving the assault is most important, and she did what was needed to stay alive
- D. take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
- E. tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (B), providing reassurance (C), and ensuring a private setting (D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
A client is demonstrating confusion as a result of bed rest and a prolonged length of hospital stay. The client receives a prescription for progressive ambulation as tolerated. Which is the best nursing intervention to use to implement the prescription?
- A. Ambulate to the client's bathroom three times a day.
- B. Ambulate in the room for short distances frequently.
- C. Ambulate in the hall progressively three times a day.
- D. Assist with range-of-motion exercises three times a day.
Correct Answer: C
Rationale: The cause of the client's confusion is bed rest and decreased sensory stimulation from a prolonged length of stay; therefore, the best intervention is to ambulate the client in the hall to increase sensory stimulation. Hopefully the stimulation can help decrease the confusion. Options 1 and 2 do not address the client's need for sensory stimulation. The nurse performs option 4 in preparation for ambulation while the client is on bed rest.
The nurse provides care for a client diagnosed with substance abuse. The nurse recognizes the client is using projection as a defense mechanism when the client makes which statement?
- A. There is genetic predisposition in my family to alcoholism.
- B. My spouse takes handfuls of medications, and I don't do that.
- C. I have one or two glasses of wine at dinner with my spouse.
- D. Many psychologists do not believe addiction is a disease.
Correct Answer: B
Rationale: Projection involves attributing one's own undesirable behaviors to others. The client blaming their spouse for excessive medication use reflects projection by deflecting their own substance abuse issues onto another person.