Nokea
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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The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. An apple
- D. A milkshake
Correct Answer: C
Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.
The nurse is reinforcing teaching to a client who is newly diagnosed with conversion disorder. The client begins crying and states, 'The health care provider must think I’m crazy because of my diagnosis.' What is the best response to the client?
- A. Conversion disorder is a diagnosis that acknowledges your symptoms are real, even if there isn’t a physical cause
- B. I am very sorry to hear this, but are you sure that’s what the provider meant? Maybe you misunderstood
- C. The health care provider is probably wrong. I’ll give you the information to contact my health care provider
- D. Why do you think you were diagnosed with conversion disorder?
Correct Answer: A
Rationale: Reassuring the client that conversion disorder validates real symptoms without a physical cause reduces stigma and clarifies the diagnosis. Other responses dismiss, question, or deflect the client’s concerns.
The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply.
- A. Avoid driving while taking this medicine
- B. Change positions slowly
- C. Discontinue immediately if suicidal thoughts occur
- D. Notify the health care provider of tarry stools
- E. Take the medicine with food
Correct Answer: D,E
Rationale: Tarry stools indicate potential GI bleeding, a serious naproxen side effect, and taking with food reduces GI irritation. Driving, position changes, and suicidal thoughts are not primary concerns with naproxen.
The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse?
- A. A sitting position is assumed as the head is bowed slightly forward
- B. The client points the spray tip toward the nasal septum during instillation
- C. The nasal spray tip is inserted into the nostril as the other nostril is occluded
- D. While administering the medication, the client inhales deeply through the nose
Correct Answer: B
Rationale: Pointing fluticasone toward the nasal septum risks irritation or bleeding; it should be aimed laterally. Sitting with head forward, occluding the other nostril, and inhaling deeply are correct administration techniques.
The nurse is evaluating the effectiveness of the medication regimen for a client with chronic kidney disease who is receiving sodium polystyrene sulfonate. It would indicate that the medication regimen has been effective if the client’s most recent laboratory test results indicate
- A. an increase in the serum calcium level
- B. an increase in the serum creatinine level
- C. a decrease in the serum potassium level
- D. a decrease in the serum phosphate level
Correct Answer: C
Rationale: Sodium polystyrene sulfonate treats hyperkalemia in chronic kidney disease by exchanging sodium for potassium in the gut, so a decreased potassium level indicates effectiveness. Calcium levels are not directly affected, and rising creatinine indicates worsening kidney function.