Nokea
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
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The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.
The nurse provides care for a client diagnosed with paranoid schizophrenia. The client’s spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?
- A. Assign the client to straighten up the day room.
- B. Establish a trusting nurse-client relationship.
- C. Encourage the client to sleep and offer a sleep aid.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Encouraging sleep and offering a sleep aid addresses the client’s insomnia, which can exacerbate paranoia and schizophrenia symptoms. A trusting relationship is important but less urgent, and other options do not address the immediate need for rest.
A client recovering from a brain attack (stroke) has become irritable and angry regarding self-limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable?
- A. Ignore the behavior, knowing that the client is grieving.
- B. Allow longer and more frequent visitation by the spouse.
- C. Use supportive statements to correct the client's behavior.
- D. Stress that the nurses are experienced and know how the client feels.
Correct Answer: C
Rationale: Clients who have experienced a stroke have many and varied needs. It is also important to support and praise the client for accomplishments. The client may need her or his behavior pointed out so that correction can take place, and the client's behavior should not be ignored. Spouses of a stroke client are often grieving; therefore, more visitations may not be helpful. Additionally, short visits are often encouraged. Stating that the nurse knows how the client feels is inappropriate.
A postoperative client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued as a result of an infiltration. Which appropriate statement should the nurse make to the client?
- A. This is usually a painless experience. It is nothing to worry about.'
- B. I'm sure it will be a real relief for you just as soon as I discontinue this IV for good.'
- C. Just relax and take a deep breath. This procedure will not take long, and it will be over soon.'
- D. I can see that you're anxious. Removal of the IV shouldn't be painful, but the IV will need to be restarted in another location.'
Correct Answer: D
Rationale: The correct option addresses the client's anxiety and honestly informs the client that the IV may need to be restarted. This option uses the therapeutic technique of giving information, and it also acknowledges the client's feelings. Although discontinuing an IV is a painless experience, it is not therapeutic to tell a client not to worry. Option 2 does not acknowledge the client's feelings, and it does not tell the client that an infiltrated IV may need to be restarted. Option 3 does not address the client's feelings.
The nurse conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.