Nokea
The nurse discovers a hospice client has expired. The family members are assembled in the facility's waiting room. Which of the following statements by the nurse would be the most appropriate?
- A. My condolences on the passing of your family member. You may visit him if you wish.
- B. I will give you some time to spend with your loved one. Let me know if you need anything.
- C. You should view your loved one as a way of saying farewell.
- D. It would be best if you not view your loved one just yet.
Correct Answer: B
Rationale: This statement offers support, gives the family autonomy, and invites further communication, which is sensitive and appropriate.
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A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
- A. Ongoing fluid restriction
- B. The need for genetic counseling
- C. The risk of hypotensive episodes
- D. Depression regarding massive edema
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
The nurse is caring for an elderly female client who presents as being alert and oriented. In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?
- A. call a family member to come and stay with the client
- B. call the health care provider and ask for an order for Xanax
- C. reorient the client and offer distraction and reassurance in a soft voice
- D. tell the client that if she does not cooperate, she will be placed in restraints
Correct Answer: C
Rationale: This behavior suggests sundowning, common in elderly clients. Reorientation and reassurance are appropriate non-pharmacological interventions.
A young female client hospitalized on the inpatient psychiatric unit receives treatment for anorexia nervosa. Which statement made by the client to the nurse best indicates improvement?
- A. The client states, 'I realize I am too thin and that it is not good for me, but I do not know how to eat more without getting fat.'
- B. The client requests a sanitary pad, saying, 'I did not think to bring anything with me. I have not had a period for months.'
- C. The client states, 'Either the food here is getting better or my appetite is coming back, but lately I find myself looking forward to meals.'
- D. The client asks for her discharge date to be delayed and says, 'I do not feel ready yet to deal with the tension in my family and their demands for perfection.'
Correct Answer: C
Rationale: Looking forward to meals indicates improved appetite and a positive shift in attitude toward eating, a key sign of progress in anorexia treatment. Other statements reflect awareness, physical changes, or anxiety, but do not directly indicate improved eating behavior.
The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.
- A. diarrhea
- B. nausea
- C. urge to urinate
- D. anxiety
Correct Answer: B
Rationale: Nausea is a common symptom of fentanyl intoxication. Diarrhea, urge to urinate, and anxiety are not typical physiological signs.
The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?
- A. The client no longer experiences phobias and anxiety.
- B. The client no longer counts objects out loud.
- C. The client is no longer mute and withdrawn.
- D. The client no longer displays overreaction to events.
Correct Answer: C
Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.