Nokea
The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
- A. I am in control of myself now.
- B. I need to use the restroom right away.
- C. I'd like to go back to my room and be alone for a while.
- D. I can't breathe in here. It feels like the walls are closing in on me.
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.
You may also like to solve these questions
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
- A. The client verbalizes the need to avoid snacking between meals.
- B. The client discusses the relationship between mealtime and the blood glucose level.
- C. The client maintains a normal weight or gradually gains weight if it is below normal.
- D. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein.
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest?
- A. The child insists that his mother stay in the room.
- B. The child is coloring and drawing pictures in a notebook.
- C. The mother keeps providing new activities for the child to do.
- D. The child sucks his thumb whenever he does not get what he asked for.
Correct Answer: B
Rationale: According to Jean Piaget, for the preschooler, play is the best way for children to understand and adjust to life's experiences. They are able to use pencils and crayons, and they can draw stick figures and other rudimentary things. A child with scarlet fever needs quiet play, and drawing will provide that. Based on this information, none of the remaining options address positive coping mechanisms.
A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?
- A. The child is free of diarrhea.
- B. The child is free of bloody stools.
- C. The child tolerates dietary wheat and rye.
- D. A balanced fluid and electrolyte status is noted on the laboratory results.
Correct Answer: A
Rationale: Watery diarrhea is a frequent clinical manifestation of celiac disease. The absence of diarrhea indicates effective treatment. Bloody stools are not associated with this disease. The grains of wheat and rye contain gluten and are not allowed. A balance of fluids and electrolytes does not necessarily demonstrate the improved status of celiac disease.
The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement?
- A. I need to avoid doing anything where there would be rough contact with the ICD insertion site.
- B. I can perform activities such as swimming, driving, or operating heavy equipment as I need to do them.
- C. I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cut-off on the ICD.
- D. I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors as well as running motors.
Correct Answer: B
Rationale: The client should avoid activities like swimming, driving, or operating heavy equipment until cleared by the healthcare provider, as these could pose risks related to the ICD function or sudden cardiac events. The other statements reflect appropriate self-care measures: avoiding rough contact protects the insertion site, avoiding strenuous activities prevents triggering the ICD, and avoiding electromagnetic sources minimizes interference with the device.
The nurse has been encouraging the intake of oral fluids for a client in labor to improve hydration. Which indicates a successful outcome of this action?
- A. Ketones in the urine
- B. A urine specific gravity of 1.020
- C. A blood pressure of 150 / 90mmHg
- D. The continued leaking of amniotic fluid during labor
Correct Answer: B
Rationale: Urine specific gravity measures the concentration of the urine. During the first stage of labor, the renal system has a tendency to concentrate urine. Labor and birth require hydration and caloric intake to replenish energy expenditure and promote efficient uterine function. An elevated blood pressure and ketones in the urine are not expected outcomes related to labor and hydration. After the membranes have ruptured, it is expected that amniotic fluid may continue to leak.