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The nurse in the mental health unit is observing staff members communicating with assigned clients. Which of the following statements by a staff member to a client would require the nurse to intervene?
- A. I do not understand what you mean. Can you give me an example?
- B. I understand that you believe the government is out to get you
- C. If you feel comfortable, could you elaborate on how your child died?
- D. Why did you get so angry when your spouse ignored you?
Correct Answer: D
Rationale: Asking 'why' can seem judgmental and provoke defensiveness, hindering therapeutic communication. Seeking clarification, acknowledging beliefs, and inviting elaboration are appropriate and supportive.
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An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?
- A. Give her a bed bath and make her bed. Get her up in the chair later.
- B. Get her up in the chair and have her give herself a bath while the nurse makes the bed.
- C. Give her a bed bath and come back later to get her up in the chair. Make the bed while she is up in the chair.
- D. Give her a bed bath and immediately get her up in the chair so the bed can be made.
Correct Answer: C
Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.
The nurse in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations should the nurse reinforce for this client? Select all that apply.
- A. Decreased daily intake of dairy products
- B. Increased intake of fruits and vegetables
- C. Moderate-intensity exercise regularly
- D. One stimulant laxative daily for a week
- E. Two cups of hot coffee each morning
Correct Answer: B,C
Rationale: Fruits and vegetables provide fiber, and exercise promotes bowel motility, relieving constipation. Dairy may worsen constipation, stimulant laxatives are not first-line in pregnancy, and coffee is not a primary solution.
A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks why, the client responds, 'Because I’m not depressed!' What is the nurse’s most appropriate response?
- A. Depression is common with fibromyalgia, but a low dose of this drug can prevent it
- B. It can relieve your chronic pain and help you sleep better at night
- C. It helps to relieve the adverse effects of your other prescribed drugs
- D. You have the right to refuse. I will notify your health care provider (HCP)
Correct Answer: B
Rationale: Duloxetine treats fibromyalgia pain and improves sleep, addressing the client’s misconception without focusing on depression. Other responses are inaccurate or dismissive.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
- A. Widening pulse pressure
- B. Pleural friction rub
- C. Distended neck veins
- D. Bradycardia
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.