Nokea
The nurse performs a physical assessment and collects the client's health history. Which assessment findings would the nurse expect to note as the client discusses the phobia related to flying? Select all that apply.
- A. Hypotension
- B. Tachycardia
- C. Tremors
- D. Shortness of breath
- E. Uncontrollable crying
- F. Facial tics
Correct Answer: B,C,D
Rationale: Discussing the phobia triggers anxiety, leading to tachycardia, tremors, and shortness of breath due to sympathetic activation.
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The 19-year-old is given a court order to enter treatment for cocaine abuse. The client threatens to leave the treatment facility AMA. Which statement by the nurse demonstrates an accurate understanding of the client’s options?
- A. “The client is of legal age and can leave on his own will; we can’t stop him from leaving.”
- B. “Due to the court order the client is not allowed to leave and will be placed in seclusion.”
- C. “The client is allowed to leave as long as the court is informed; I’ll prepare the documents.”
- D. “The client cannot leave and will be returned to treatment or another option by court order.”
Correct Answer: D
Rationale: Court-ordered clients cannot leave voluntarily (D). Age (A) is irrelevant seclusion (B) is illegal informing court (C) doesn’t allow leaving.
If a client is typical of other victims who remain in abusive relationships, what is the client most likely to believe?
- A. The client is not in any serious danger.
- B. The client can turn to the family for protection.
- C. The client can prevent the battering behavior.
- D. The client is free to leave the home at any time.
Correct Answer: C
Rationale: Victims often believe they can control or prevent the abuse, reflecting denial or rationalization that keeps them in the abusive situation.
The client is admitted to the ED with multiple lacerations and broken bones after being assaulted. The client’s spouse barges into the client’s ED room with a gun and states “I’m going to kill you and anyone else who gets in my way.” Which action should be taken by the nurse initially?
- A. Yell for help to distract the person’s attention away from the client.
- B. Firmly state “You don’t want to hurt anyone else. Let’s talk about it.”
- C. Use gestures to alert another nurse to clear others who may be nearby.
- D. Use a nonaggressive posture and tone to state “Put the gun on the floor.”
Correct Answer: D
Rationale: Using a nonaggressive posture and tone (D) to request the gun be placed down de-escalates the situation safely. Yelling (A) may startle and escalate assuming intent (B) blocks communication and gesturing (C) risks escalation if noticed.
Which action by the nurse can best determine if an older client's inappropriate responses to several questions are due to miscommunication or to impaired cognition?
- A. Ask the client to repeat the question before answering it.
- B. Ask questions that require only a 'yes' or 'no' response.
- C. Ask the client's next of kin for answers to the questions.
- D. Ask questions to which the client is sure to know the answers.
Correct Answer: A
Rationale: Having the client repeat the question clarifies whether misunderstanding or cognitive impairment caused the inappropriate response.
If the client's pain is the result of a panic attack, which findings will the nurse most likely note during the physical assessment? Select all that apply.
- A. Tachycardia
- B. Hypotension
- C. Increased salivation
- D. Constricted pupils
- E. Sweating
- F. Unsteady gait
Correct Answer: A,E
Rationale: Panic attacks typically cause tachycardia and sweating due to sympathetic nervous system activation, reflecting acute anxiety.