Nokea
The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.
You may also like to solve these questions
A client who is postmenopausal asks the nurse how to prevent osteoporosis. Which statement should the nurse make to the client?
- A. Eat 2 ounces of cheese each day and walk a mile a day.
- B. There are no known ways to prevent osteoporosis.
- C. Do weight-bearing exercises regularly and take hormones as ordered by your physician.
- D. Take potassium supplements daily.
Correct Answer: C
Rationale: Weight-bearing exercises and hormone therapy (if prescribed) are evidence-based methods to prevent osteoporosis, unlike the other options.
The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
- A. 1 year
- B. 5 years
- C. 10 years
- D. The rest of his life
Correct Answer: D
Rationale: Lifelong immunosuppression is required post-transplant to prevent organ rejection.
The nurse is caring for a client whose native language is Korean; he speaks only a few words of English. The health care provider has determined that the client needs to undergo a coronary artery bypass graft. Which is the appropriate action by the nurse?
- A. ask the client's spouse to give consent for the procedure before explaining it to the client
- B. ask the client's spouse to translate for the health care provider and explain the procedure to the client
- C. communicate with the client by showing pictures of the intended surgery while a family member translates
- D. request a licensed translator to interpret for the health care provider and client during the conversation
Correct Answer: D
Rationale: A licensed translator ensures accurate communication and informed consent, adhering to ethical and legal standards.
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history?
- A. Post-coital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Post-coital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor friability. The other symptoms are less specific or related to advanced disease.
The initial assessment of a newborn reveals a chest circumference of 34 cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
- A. Providing supplemental oxygen by a ventilated mask
- B. Performing auscultation of the abdomen for the presence of active bowel sounds
- C. Inserting a nasogastric tube to check for esophageal patency
- D. Positioning on the left side with head and chest elevated
Correct Answer: A
Rationale: Diminished breath sounds and chest asymmetry suggest a respiratory issue, such as pneumothorax, requiring immediate supplemental oxygen.