Nokea
The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?
- A. Provide music for the client
- B. Use gentle touch to calm the client
- C. Instruct the client to ignore the hallucinations
- D. Tell the client the medication will alleviate the hallucinations within a few hours
Correct Answer: C
Rationale: Instructing the client to ignore hallucinations helps them manage symptoms by redirecting focus, a practical coping strategy. Music or touch may exacerbate distress, and antipsychotics typically take days to weeks to reduce hallucinations, not hours.
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The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching?
- A. I will allow my child to have a snack while using the HFCWO vest to encourage cooperation.
- B. I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest.
- C. I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable.
- D. My child will use the HFCWO vest once in the morning, once in the evening, and as needed.
Correct Answer: A
Rationale: Eating during HFCWO vest use can increase the risk of aspiration or reduce therapy effectiveness, indicating a need for further teaching. Bronchodilators during therapy, manual percussion as a backup, and the described frequency are appropriate.
The nurse is providing diversional activities for a 4-year-old client who is on long-term, strict bed rest. Which of the following toys would be most appropriate to provide for the client?
- A. Card game
- B. Board game
- C. Soap bubbles
- D. Plastic medical kit
Correct Answer: C
Rationale: Soap bubbles are safe, engaging, and can be used while on strict bed rest, promoting activity without physical exertion. Card and board games may require setup or movement, and a medical kit may cause anxiety.
The family carries out its health care functions in which of the following ways?
- A. Family provides very little preventive health care to its members at home.
- B. Family provides sick care to its members.
- C. Family pays for most health services.
- D. Family decides when and where to hospitalize its members.
Correct Answer: B
Rationale: Families often provide sick care, such as administering medications or monitoring symptoms, as a primary healthcare function. The other options are less accurate or overly specific. Prevention and Early Detection of Disease
The nurse is teaching a client about the use of Rifampin for prophylaxis after an exposure to meningitis. What change in bodily functions should the nurse advise the client about?
- A. The client's urine might turn blue.
- B. The client remains infectious to others for 48 hours.
- C. The client's contact lenses might be stained orange.
- D. The client's skin might take on a crimson glow.
Correct Answer: C
Rationale: Rifampin causes body fluids to turn orange, potentially staining soft contact lenses permanently. The other effects are not associated with Rifampin. Safety and Infection Control
Social support systems include all of the following except:
- A. call-in help lines.
- B. emotional assistance provided by others.
- C. community support groups.
- D. use of coping skills and verbalization for anger management.
Correct Answer: D
Rationale: Coping skills and verbalization are personal strategies, not social support systems, which involve external resources like help lines, emotional assistance, or groups. Psychosocial Integrity