Nokea
The nurse in the outpatient mental health clinic develops a plan of care for a client diagnosed with bulimia. The nurse determines that which goal is most important?
- A. The client will identify symptoms of electrolyte imbalance.
- B. The client will maintain dental appointments and oral hygiene.
- C. The client will attend appropriate community support groups.
- D. The client will abstain from binge-purge behaviors.
Correct Answer: D
Rationale: Abstaining from binge-purge behaviors is the primary goal for bulimia treatment, as these behaviors drive the disorder's physical and psychological harm. Other goals support recovery but are secondary to stopping the cycle.
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The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
- A. Document that the client responds to the painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the health care provider.
Correct Answer: A
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?
- A. Encourage the client to use a nicotine patch.
- B. Reassure the client that it is almost time for another break.
- C. Have the client leave the unit with another staff member.
- D. Review the schedule of outdoor breaks with the client.
Correct Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Suggesting a nicotine patch (Option A) is not suitable as the client wants to smoke. Reassuring the client about another break (Option B) does not address the client's frustration and does not promote effective communication. Having the client leave the unit with another staff member (Option C) is not appropriate as it goes against unit rules and does not address the client's concerns. Therefore, the most appropriate intervention is to review the schedule of outdoor breaks with the client to provide clarity and address the client's frustration effectively.
The nurse is preparing to implement suicide precautions for an acutely suicidal client. Which nursing interventions are included with regard to these precautions?
- A. Maintain arm's length distance with the client at all times.
- B. Ensure that meal trays contain no glass or metal silverware.
- C. Carefully watch the client swallow each dose of medication.
- D. Conduct one-on-one nursing observation and interaction 24 hours a day.
- E. Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol.
- F. Allow the client to totally cover self with the bedcovers during sleep at night as long as the nurse is present.
Correct Answer: A,B,C,D,E
Rationale: Suicide precautions involve constant observation of the client by the nursing staff. This intense attention from the nurse provides for safety and also allows for constant reassessment of risk. Suicide precautions include maintaining arm's length distance with the client at all times; ensuring that meal trays contain no glass or metal silverware; carefully watching the client swallow each dose of medication; conducting one-on-one nursing observation and interaction 24 hours a day and explaining to the client the procedures involved with suicide precautions; and documenting client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol. During observation when the client is sleeping, the client's hands should always be in view and not under the bedcovers.
While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most important health promotion brochure to provide to an obese client newly diagnosed with arteriosclerosis is one focused on decreasing cholesterol levels through diet. Arteriosclerosis is significantly influenced by excess dietary fat, especially saturated fat and cholesterol. Monitoring blood pressure at home, while important, does not directly address the underlying cause of arteriosclerosis. Smoking cessation and stress management are crucial for overall cardiovascular health, but lowering cholesterol through diet takes precedence in this scenario.