Nokea
The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions is MOST appropriate?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with headphones.
- C. Instruct the client to ignore the voices completely.
- D. Administer an antipsychotic medication as ordered.
Correct Answer: B
Rationale: Listening to music with headphones can distract from auditory hallucinations, reducing their intensity. Arguing (A) increases agitation, ignoring voices (C) is ineffective, and administering medication (D) is appropriate but not the most immediate non-pharmacologic intervention.
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An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
- A. Expected
- B. Rude
- C. Professional
- D. Enjoyable
Correct Answer: B
Rationale: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.
A client with Anemia has been prescribed liquid iron. Which would the nurse expect to be included in the teaching plan?
- A. Take the medication through a straw.
- B. Administer this drug mixed with coffee.
- C. The drug causes the urine to turn black.
- D. The drug must be stored in the refrigerator.
Correct Answer: A
Rationale: Liquid iron should be administered through a straw to prevent dental staining. Answers B, C, and D are not correct instructions for taking liquid iron, so they are incorrect.
The nurse is caring for a person who is admitted with progressive amyotrophic lateral sclerosis (ALS). What nursing care measure should the nurse expect to be ordered for this client?
- A. Change dressing daily
- B. Monitor IV fluids
- C. Insert indwelling catheter
- D. Chest physical therapy (PT) qid
Correct Answer: D
Rationale: ALS causes respiratory muscle weakness; chest PT helps clear secretions, preventing pneumonia. Dressings, fluids, or catheters are not primary.
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
- A. touching the trapezius muscle or arm firmly
- B. pinching any body part
- C. shaking a limb vigorously
- D. rubbing the sternum
Correct Answer: D
Rationale: rubbing the sternum. The purpose is to assess the non-responsive client's reaction to a painful stimulus after less noxious methods have been tried.