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The nurse is caring for a client with schizophrenia. The client appears anxious and states, 'The voices are bad today; they sound so angry with me.' Which of the following responses would be most appropriate for the nurse to make?
- A. You should not listen to the voices.
- B. Remember that the voices are not real. Tell the voices to go away.
- C. What are the voices saying to you?
- D. That sounds frightening. Would you like medication to help you feel less anxious?
Correct Answer: D
Rationale: Acknowledging the client's fear and offering medication (D) is therapeutic and addresses anxiety. Dismissing voices (A, B) or probing content (C) may increase distress or reinforce delusions.
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The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include?
- A. Arrange furniture to allow for free movement
- B. Keep frequently used items within easy reach
- C. Lock doors leading to stairwells and outside areas
- D. Place an identifying symbol on the bathroom door
- E. Provide a dark room free of shadows for sleeping
Correct Answer: A,B,C,D
Rationale: Clear pathways (A), accessible items (B), locked doors (C), and bathroom symbols (D) enhance safety. A dark room (E) may increase confusion or fear.
The nurse is talking with a client whose spouse recently died. The client states, 'I just cannot get over my spouse's death.' Which of the following responses would be appropriate for the nurse to make?
- A. A friend of mine recently died. I know how hard losses can be.
- B. It may take a while, but coming to terms with loss will get easier with time.
- C. I see that you are upset. I will give you some time alone so you can process these feelings.
- D. Have you considered attending a support group to help you process grief?
- E. This is a difficult time. Tell me about how you have been coping.
Correct Answer: B,D,E
Rationale: The nurse should provide empathetic, open-ended responses that encourage the client to express feelings and explore coping strategies. Suggesting a support group (D) and asking about coping methods (E) are therapeutic. Acknowledging that grief takes time (B) is supportive. Sharing personal experiences (A) is unprofessional, and leaving the client alone (C) may dismiss their emotional needs.
A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?
- A. Take this in the morning 1 hour before breakfast.
- B. Take this with your other stomach medications.
- C. Take your heart medication 2 hours after sucralfate.
- D. You might experience constipation while taking this.
Correct Answer: B
Rationale: Sucralfate (B) should not be taken with other stomach medications, as it forms a protective barrier, reducing their absorption. Timing (A, C) and constipation (D) are correct.
The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?
- A. prolonged inspiration with each breath
- B. expiratory wheezes that are suddenly absent in 1 lobe
- C. expectoration of large amounts of purulent mucous
- D. appearance of the use of abdominal muscles for breathing
Correct Answer: B
Rationale: Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Sudden cessation of wheezing is an ominous sign that indicates an emergency -- the small airways are now collapsed.
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should
- A. Eat foods high in sodium to increase sputum liquefaction
- B. Use oxygen during meals to improve gas exchange
- C. Perform exercise after respiratory therapy to enhance appetite
- D. Cleanse the mouth of dried secretions to reduce risk of infection
Correct Answer: B
Rationale: Use oxygen during meals to improve gas exchange. This supports breathing and energy needs during eating.