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The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?
- A. Poor self-care
- B. Body image insecurity
- C. Neck range of motion restrictions
- D. Uncontrolled pain related to the CVC
Correct Answer: B
Rationale: Psychosocial assessment includes client data related to psychological and social issues. The CVC can create socially awkward situations and impair the client's security in her body image. The client data presented do not support assessing the client for poor self-care. Although pain and neck range of motion are valid issues for this client, options 3 and 4 are physiological issues and do not relate to the concerns of the client.
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The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. help the client bathe and change into fresh clothing before the examination begins
- B. preserve any evidence, including clothing, and take photographs of injuries as appropriate
- C. assure the client that surviving the assault is most important, and she did what was needed to stay alive
- D. take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
- E. tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (B), providing reassurance (C), and ensuring a private setting (D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
The nurse manager of the psychiatric unit plans the biweekly, unit-wide interdisciplinary team case conference focused on one particular client. Which client is most important for the manager to select for discussion?
- A. A client who was admitted after a second serious suicide attempt and refuses to talk.
- B. A client toward whom the staff have sharply conflicting attitudes and actions.
- C. A client who experiences hallucinations, takes possessions from other clients, and paces continually.
- D. A client, well known and well liked by staff, whose diagnostic testing reveals a brain tumor.
Correct Answer: A
Rationale: A client with a recent serious suicide attempt who refuses to talk is at high risk for self-harm and requires urgent interdisciplinary discussion to coordinate safety and treatment plans. Other cases, while significant, are less immediately life-threatening.
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
- A. Risk of tachycardia
- B. Probability of fatigue
- C. High incidence of hypoglycemia
- D. Possible exacerbation of depression
Correct Answer: D
Rationale: Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia rather than tachycardia. Fatigue is a possible side effect, but it is not the most important item. Hypoglycemia is a sign that is masked with beta blockers.
A client diagnosed with catatonic schizophrenia demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. Which intervention by the nurse is most appropriate to increase interpersonal communication?
- A. Ask the client direct questions to encourage talking.
- B. Leave the client alone and intermittently check on her or him.
- C. Sit beside the client in silence and occasionally ask open-ended questions.
- D. Take the client into the dayroom with the other clients, to encourage interaction.
Correct Answer: C
Rationale: Clients who are withdrawn may be immobile and mute, and they require consistent, repeated approaches. Intervention includes the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. Asking this client direct questions is not therapeutic. The client is not to be left alone. This client is not capable of interaction in the dayroom.
A nurse in the outpatient clinic receives four phone messages. Which call does the nurse return first?
- A. The parent of a preschool-age child who continuously throws temper tantrums, is always moving, and is impulsive.
- B. The parent whose adolescent child has vomited every day for 2 weeks and now weighs 74 pounds.
- C. The parent who receives calls from the school about an adolescent child's aggressive behavior toward schoolmates.
- D. The adult child of an older adult who is having difficulty sleeping after a spouse died 2 weeks ago.
Correct Answer: B
Rationale: An adolescent vomiting daily for 2 weeks and weighing 74 pounds indicates a critical health issue, likely severe dehydration or malnutrition, requiring urgent assessment to prevent life-threatening complications. This takes priority over behavioral, aggression, or grief-related concerns.