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The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?
- A. Ask the client to describe the history of the injuries.
- B. Invite a colleague to document during the interview.
- C. Close the examination room door for privacy.
- D. Request hospital security to come to the department.
Correct Answer: C
Rationale: Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history, facilitating open communication.
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An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Disturbed sensory perception.
- B. Compromised family coping.
- C. Ineffective sexual patterns.
- D. Impaired environmental interpretation.
Correct Answer: A
Rationale: The client's statements suggest a distorted perception of reality, indicating disturbed sensory perception, which addresses potential psychosis and immediate safety concerns.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
- A. Advise the mother to call the police if violent behavior occurs again.
- B. Refer the mother for psychiatric evaluation for anxiety and depression.
- C. Reinforce the need for the adolescent to attend group therapy sessions.
- D. Tell the mother to describe her feelings of helplessness to her son.
Correct Answer: A
Rationale: Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others, ensuring appropriate intervention.
A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
- A. Help the client identify thoughts that may be triggers.
- B. Explore past behaviors that have provided relief.
- C. Attempt to distract to another focus or activity.
- D. Speak calmly to the client stating assurance of safety.
Correct Answer: D
Rationale: Speaking calmly and providing assurance of safety is the first step in managing severe anxiety, helping to stabilize the client.
During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don't remember, but my mother ran my father off when I was five.†The nurse should recognize that the client may be using which defense mechanism?
- A. Regression.
- B. Projection.
- C. Denial.
- D. Repression.
Correct Answer: D
Rationale: Repression involves unconsciously blocking out memories, and the client's inability to recall potential abuse suggests this defense mechanism.