Nokea
The nurse is assessing a client's emotional state and coping strategies. Evidence of which behavior is of most concern to the nurse?
- A. Anxiety
- B. Dysfunctional family unit
- C. Social isolation
- D. Self-mutilation
Correct Answer: D
Rationale: Self-mutilation indicates severe emotional distress and risk of harm, the most concerning behavior requiring immediate intervention.
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The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
- A. putting together a puzzle in the activity room
- B. reading an age-appropriate book
- C. walking down the unit hallways
- D. playing with finger puppets
Correct Answer: B
Rationale: Reading a book (B) is a calm, stationary activity suitable for pain management. Puzzles (A) may require movement, walking (C) could worsen pain, and puppets (D) may be too childish for a 10-year-old.
The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
- A. Ask the interpreter to explain the discussion
- B. Confirm the client's consent with the interpreter, using gestures
- C. Have the interpreter witness the signature
- D. Indicate that the interpreter was used when witnessing the client's signature
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (B) are unreliable, the interpreter witnessing (C) is inappropriate, and noting interpreter use (D) is insufficient without understanding the discussion.
An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
- A. Encouraging frequent fluid intake
- B. Keeping the bed elevated and side rails raised
- C. Providing one-on-one supervision
- D. Turning the lights off in the client's room
Correct Answer: C
Rationale: One-on-one supervision (C) ensures safety for a confused, agitated client at risk for falls or harm. Fluids (A), side rails (B), and dim lights (D) are secondary or inappropriate.
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?
- A. Administer PRN albuterol by nebulizer
- B. Assist with guided imagery to relieve anxiety
- C. Elevate the head of the bed
- D. Give PRN sublingual morphine
Correct Answer: C
Rationale: Elevating the head of the bed (C) is the first non-pharmacologic intervention to ease breathing in heart failure by reducing pulmonary congestion. Albuterol (A) is for bronchospasm, imagery (B) is secondary, and morphine (D) is for severe distress.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.