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The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?
- A. Do you have any questions about the diagnosis?
- B. There are medications available to treat Alzheimer disease.
- C. This new diagnosis must be frightening for you.
- D. We can help you make decisions about your care.
Correct Answer: C
Rationale: Acknowledging the emotional impact of the diagnosis validates the client's and spouse's feelings, fostering therapeutic communication and trust.
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A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
- A. Hair loss
- B. Nausea
- C. Petechiae
- D. Stomatitis
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?
- A. Bronchial breath sounds at lung periphery
- B. Clear vesicular breath sounds at lung bases
- C. Diffuse bilateral crackles at lung bases
- D. Stridor in upper airways
Correct Answer: C
Rationale: Frothy, pink-tinged sputum and dyspnea indicate pulmonary edema, a complication of myocardial infarction. Diffuse bilateral crackles are heard due to fluid in the alveoli.
The practical nurse collaborates with the registered nurse to perform an admission assessment on a client with Alzheimer disease. Which of the following techniques are appropriate when speaking with this client? Select all that apply.
- A. Ask open-ended questions
- B. Move close to the client and speak in a loud voice
- C. Remove background noise by turning off the television
- D. Touch the client on shoulder prior to speaking
- E. Use clear and simple sentences
Correct Answer: C,D,E
Rationale: Reducing background noise (C) minimizes distractions. Touching the shoulder (D) gains attention non-verbally. Using clear, simple sentences (E) accommodates cognitive impairments in Alzheimer disease.