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The nurse is caring for an elderly female client who presents as being alert and oriented. In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?
- A. call a family member to come and stay with the client
- B. call the health care provider and ask for an order for Xanax
- C. reorient the client and offer distraction and reassurance in a soft voice
- D. tell the client that if she does not cooperate, she will be placed in restraints
Correct Answer: C
Rationale: This behavior suggests sundowning, common in elderly clients. Reorientation and reassurance are appropriate non-pharmacological interventions.
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The nurse is assessing a client who is a polysubstance abuser, with fentanyl being one of the drugs most frequently used. Which physiological symptoms are suggestive of fentanyl intoxication? Select all that apply.
- A. diarrhea
- B. nausea
- C. urge to urinate
- D. anxiety
Correct Answer: B
Rationale: Nausea is a common symptom of fentanyl intoxication. Diarrhea, urge to urinate, and anxiety are not typical physiological signs.
An English-speaking Hispanic client has a newly applied long leg cast to stabilize a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and unusually quiet. Which nursing statement would be most appropriate?
- A. Are you uncomfortable?
- B. Tell me what you are feeling.
- C. You'll feel better in the morning.
- D. I'll get your pain medication right away.
Correct Answer: B
Rationale: Option 2 is open-ended and makes no assumptions about the client's psychological or emotional state. Option 1 is incorrect because males in traditional standard Hispanic cultures practice 'machismo' in which stoicism is valued, so this client may deny any pain when asked. False reassurance is never therapeutic, which makes option 3 incorrect. Option 4 is incorrect because an assessment is necessary before administering medication for pain.
A primigravida client who came to the clinic has been diagnosed with a urinary tract infection. She repeatedly verbalizes concern regarding the safety of the fetus. Which should the nurse address first?
- A. Maternal and infant safety
- B. Obtaining a sedative prescription
- C. Instructions regarding improved hygiene
- D. Instructions regarding medication compliance
Correct Answer: A
Rationale: The primary concern of this client is the safety of her fetus rather than herself. The priority for the nurse to address at this time is the issues regarding safety. The remaining options lack this priority.
The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?
- A. Encouraging the child to confront the abuser
- B. Providing a care environment that fosters trust
- C. Teaching the child to make wise choices when faced with possible abuse
- D. Reinforcing for the child that not all adults are capable of abusing children
Correct Answer: B
Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.
The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?
- A. The client no longer experiences phobias and anxiety.
- B. The client no longer counts objects out loud.
- C. The client is no longer mute and withdrawn.
- D. The client no longer displays overreaction to events.
Correct Answer: C
Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.