Nokea
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
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A client is to be discharged on enoxaparin (Lovenox) for the next two days. Which comment by the client indicates a need for further instruction?
- A. I will wash my hands before I prepare the injection.
- B. I will give the injection in my thigh.
- C. I will pinch the skin before I inject the medicine.
- D. I will not massage the area after the shot.
Correct Answer: B
Rationale: Enoxaparin is injected subcutaneously in the abdomen, not the thigh, indicating a need for further teaching.
The nurse is caring for a client with hepatic encephalopathy who is receiving lactulose. Which of the following findings would indicate that the medication has been effective?
- A. Improved mental status
- B. Looser consistency of stool
- C. Reduced abdominal distension
- D. Increased serum potassium level
Correct Answer: A
Rationale: Lactulose is used in hepatic encephalopathy to reduce ammonia levels by promoting its excretion through the stool. Improved mental status (A) indicates reduced ammonia toxicity, directly reflecting the medication's therapeutic effect. Looser stools (B) and reduced abdominal distension (C) are expected effects of lactulose but are secondary to the primary goal of ammonia reduction. Increased serum potassium (D) is incorrect, as lactulose does not directly affect potassium levels.
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?
- A. Administer promethazine suppository
- B. Initiate NPO status
- C. Insert nasogastric tube set to low suction
- D. Obtain prescription for pain medication
Correct Answer: B
Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status, B) to prevent further stimulation and complications like perforation. Promethazine (A) and pain medication (D) are supportive but secondary. A nasogastric tube (C) may be considered later but is not the priority.
The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?
- A. An appropriate form must be signed, verifying refusal
- B. Complications, including death, could result
- C. The client will be billed for the equipment regardless
- D. The surgeon will be informed of the refusal
Correct Answer: B
Rationale: SCDs prevent deep vein thrombosis (DVT) post-surgery, a potentially fatal complication. Communicating the risk of complications, including death (B), is critical to emphasize the importance of compliance. Signing a refusal form (A), billing (C), or informing the surgeon (D) are secondary to ensuring the client understands the serious risks.
The nurse has reinforced nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate a need for further teaching?
- A. Broccoli
- B. An orange
- C. Chocolate cake
- D. Fish
Correct Answer: D
Rationale: Fish should be avoided on a low-purine diet. Other foods to avoid include poultry, liver, lobster, oysters, peas, spinach, and oatmeal. Answers A, B, and C are all foods included on a low-purine diet, which makes them incorrect.