Nokea
The nurse observes that a client is restless, tense, and reports feeling empty. The nurse notes the client has a history of threatening self-mutilation. Which nursing action is appropriate?
- A. Monitor weight and dietary intake.
- B. Administer chlordiazepoxide.
- C. Provide food in client's own containers.
- D. Take inventory of the client's room.
Correct Answer: D
Rationale: Taking inventory of the client’s room ensures safety by identifying and removing potential tools for self-harm, given the history of threatened self-mutilation. Other actions do not directly address the immediate risk.
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Which intervention does the nurse include in the plan of care for a client from a different culture?
- A. Being respectful of the client's needs.
- B. Expecting non-adherent behavior.
- C. Monitoring for difficulty with dietary restrictions.
- D. Offering a firm handshake upon leaving the client.
Correct Answer: A
Rationale: Respecting the client's cultural needs promotes trust and effective care, ensuring culturally sensitive interventions. Expecting non-adherence is biased, monitoring dietary restrictions is too specific, and a handshake may not be culturally appropriate.
A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, 'I'm no good to anyone. I might as well be dead.' Which most therapeutic response should the nurse make to the client?
- A. You're not a useless person at all.'
- B. I'll ask the psychologist to see you about this.'
- C. You appear to be feeling pretty bad about things.'
- D. It makes me uncomfortable when you talk this way.'
Correct Answer: C
Rationale: Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication.
When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?
- A. Increase in pulse rate
- B. Widened pulse pressure
- C. Increase in body temperature
- D. Decrease in diastolic blood pressure
Correct Answer: B
Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.
A neonatal intensive care nurse is caring for a newborn with a suspected diagnosis of erythroblastosis fetalis. Which therapeutic statement should the nurse make to the parents at this time?
- A. Your infant is very sick. The next 24 hours are the most crucial.'
- B. This is a common neonatal problem, so the prognosis is very good.'
- C. You have reason to worry but we have everything needed to care for your baby right here in this hospital.'
- D. You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care.'
Correct Answer: D
Rationale: The nurse should use therapeutic communication to address the parents' concerns and provide an opportunity for them to ask questions about their infant's care. Option 4 encourages open dialogue and supports the parents emotionally, which is critical during this stressful time. Option 1 may heighten anxiety without offering constructive support. Option 2 inaccurately minimizes the severity of erythroblastosis fetalis. Option 3 acknowledges worry but focuses on hospital resources rather than addressing the parents' emotional needs directly.
A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial about his medical condition?
- A. Requests a sedative for sleep at 10:00 pm
- B. Expresses a hesitancy to leave the hospital
- C. Consumes 25% of foods and fluids given for supper
- D. Walks up and down three flights of stairs unsupervised
Correct Answer: D
Rationale: Ignoring activity limitations and avoiding lifestyle changes are signs of the denial stage. Walking three flights of stairs should be a supervised activity during this phase of the recovery process. Option 1 is an appropriate client action on the evening before discharge. Option 2 may be a manifestation of anxiety or fear rather than denial. Option 3 is a manifestation of depression rather than denial.