Nokea
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.
You may also like to solve these questions
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. You appear to be speaking with someone
- B. Let's talk about the next time this happens
- C. You need to be calm and focus on something else
- D. The voices you are hearing are not real
Correct Answer: A
Rationale: This comment acknowledges the client's behavior without judgment, validating their experience and encouraging further discussion. Focusing on the future, redirecting, or denying the voices may not be therapeutic and could invalidate the client's reality.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?
- A. Ineffective community coping
- B. Disturbed sensory perception
- C. Self-care deficit
- D. Acute confusion
Correct Answer: D
Rationale: Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue. While self-care deficit could be a concern, it is not the priority when the client is disoriented.
An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?
- A. Cares for an older parent and her children
- B. Anxious to leave for personal appointments
- C. Takes naps in her car during lunch hour
- D. Works an average of 60 hours per week
Correct Answer: A
Rationale: Caring for an older parent and children simultaneously indicates significant caregiver role strain due to increased responsibilities. Anxiety, napping, and long work hours suggest stress but are less specific to caregiving demands.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.
During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?
- A. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent
- B. Both the nurse and therapist are reprimanded for divulging confidential patient information to others
- C. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information
- D. The therapist is reprimanded for divulging confidential patient information without obtaining consent
Correct Answer: C
Rationale: The nurse appropriately shared the threat with the team to ensure safety, but the therapist's disclosure to the supervisor may breach confidentiality. Educating team members on appropriate information sharing balances safety and privacy. Reprimands are less constructive unless clear violations occurred.