Nokea
The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
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A client with the diagnosis of acute pyelonephritis who is very shy and modest is scheduled for a voiding cystourethrogram. Why should the nurse determine that this client would benefit from increased support and teaching about the procedure?
- A. Radioactive material is inserted into the bladder.
- B. Radiopaque contrast is injected into the bloodstream.
- C. The client must void while the voiding process is filmed.
- D. The client must lie on an x-ray table in a cold, barren room.
Correct Answer: C
Rationale: Having to void in the presence of others can be very embarrassing for clients, and it may actually interfere with the client's ability to void. The nurse teaches the client about the procedure to try to minimize stress from a lack of preparation and gives the client encouragement and emotional support. Screens may be used in the radiology department to try to provide an element of privacy during this procedure. The remaining options are incorrect and do not address the subject of support.
The nurse is developed a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication should the nurse base the teaching plan?
- A. Edema
- B. Hair loss
- C. Weight loss
- D. Decreased libido
Correct Answer: D
Rationale: The nurse should be aware of the fact that the client taking spironolactone, a potassium-sparing diuretic, may experience body image changes that result from a threatened sexual identity. These are related to decreased libido, gynecomastia in males, and hirsutism in females. Edema, weight loss, and hair loss are not specifically associated with the use of this medication.
The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.)
- A. Keep the voice even throughout conversations.
- B. Explain the sounds in the environment.
- C. Decrease background noise before speaking.
- D. Stay in the client's field of vision.
- E. Identify self by name and staff position.
Correct Answer: A,B,C,D,E
Rationale: All options are appropriate: (A) Even voice tone ensures clarity; (B) Explaining sounds reduces confusion; (C) Reducing noise aids hearing; (D) Staying in the field of vision supports communication; (E) Identifying self orients the client. These interventions enhance safety and interaction.
The nurse is educating a group of student nurses about perceived loss. The nurse knows that the students understand when one of them verbalizes which example?
- A. a single mother loses her job
- B. a student fails his college chemistry class
- C. a husband is grieving the loss of his wife of 40 years
- D. a first-time mother is disappointed that she had a boy instead of a girl
Correct Answer: D
Rationale: Perceived loss involves subjective disappointment, such as a mother's expectation of a different gender, unlike tangible losses like a job or spouse.
A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care?
- A. Attend a support group.
- B. Cease dwelling on the negative.
- C. Reach out for help to face this fear.
- D. Share her feelings with her partner.
Correct Answer: D
Rationale: Talking to the client about sharing her feelings with her husband directly addresses the subject of the question. Encouraging the client to start a support group will not address the client's immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client's concern.