Nokea
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
- A. administers medications as ordered
- B. uses gentle touch to reassure the client
- C. tells the client that others see or hear what he does
- D. distracts the client by placing him in the dayroom with others
- E. asks the client if he hears voices telling him to harm himself or others
- F. goes along with what the client says to decrease the risk of increasing the client's anxiety
Correct Answer: A,D,E
Rationale: Medications help manage hallucinations, distraction can reduce focus on hallucinations, and assessing for command hallucinations ensures safety. Touch may increase anxiety, reinforcing hallucinations is nontherapeutic, and going along with delusions can worsen confusion.
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A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?
- A. Utilize an organized team to place the client in seclusion.
- B. Allow time in the client's private assigned room for reflection.
- C. Redirect the client to a quiet activity such as journaling.
- D. Assist the client to express feelings of anger and frustration.
Correct Answer: D
Rationale: Assisting the client to express feelings helps de-escalate agitation by addressing the underlying emotions, promoting safety and therapeutic communication. Seclusion is a last resort, reflection may not address acute agitation, and journaling may not be feasible in this state.
A client is very anxious about receiving chest physiotherapy (CPT) for the first time at home. When planning for the client's care, which concept about CPT should the home care nurse use to reassure the client?
- A. CPT will help the client cough more often.
- B. There are no risks associated with this procedure.
- C. CPT will resolve all of the client's respiratory symptoms.
- D. CPT will assist with mobilizing secretions to enhance more effective breathing.
Correct Answer: D
Rationale: CPT is an intervention to assist with mobilizing and clearing secretions to enhance more effective breathing. CPT will assist the client with coughing if the secretions have been mobilized and the cough stimulus is present. There are risks associated with CPT, including cardiac, gastrointestinal, neurological, and pulmonary effects. It will not resolve all of the client's respiratory symptoms.
The home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client's pain?
- A. The client's pain rating
- B. The nurse's impression of the client's pain
- C. Verbal and nonverbal clues from the client
- D. Pain relief after appropriate nursing intervention
Correct Answer: A
Rationale: The client's perception of pain is the hallmark of pain assessment. Usually noted by the client's rating on a scale of 1 to 10, the assessment is documented and followed with appropriate medical and nursing interventions. The nurse's impression and the verbal and nonverbal clues are subjective data. Pain relief after intervention is appropriate but relates to evaluation.
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client?
- A. Noting whether the client has visitors
- B. Instructing all staff members to not touch the client
- C. Giving the client a roommate with TB who persistently tries to talk
- D. Removing the calendar and clock in the room so that the client will not obsess about time
Correct Answer: A
Rationale: The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.
While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.