Nokea
The nurse was assigned to the mental health care area from another area in the facility. A client accuses the nurse of being a terrorist with poisonous pills when the nurse is preparing medications. Which response by the nurse is best?
- A. I am not a terrorist.
- B. Is it your feeling that I am trying to poison you?
- C. This is your medication, which you have to take now.
- D. I am a nurse from another unit in this hospital.
Correct Answer: B
Rationale: Reflecting the client’s feelings validates their emotions and opens therapeutic communication without confrontation, which is critical for a client with possible paranoia. Denying, insisting, or explaining may escalate distrust.
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A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels 'as though the rape just happened yesterday.' Which statement is most appropriate for the nurse to use as a response?
- A. In reality, the rape did not just occur. It has been over 2 months now.'
- B. What can you do to alleviate some of your fears about being assaulted again?'
- C. In time, our goal will be to help you move on from these strong feelings about your rape.'
- D. Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.'
Correct Answer: D
Rationale: Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment. Although option 1 is true, it immediately blocks communication. Option 2 places the problem-solving totally on the client. Option 3 places the client's feelings on hold.
A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.
An 11-year-old child scheduled for a diagnostic procedure will have an intravenous line inserted and will receive an intramuscular injection. Which form of communication should the nurse use in preparing the child for the procedure?
- A. Reassuring the child by introducing the equipment used
- B. Teaching the parents so that they can explain everything to the child
- C. Telling the child not to worry because the doctors take care of everything
- D. Using pictures, concrete words, and demonstrations to describe what will happen
Correct Answer: D
Rationale: Using pictures, concrete words, and demonstrations is the most effective way to communicate with an 11-year-old child about a medical procedure, as it aligns with their developmental stage and helps them understand what to expect. Option 1 may not fully address the child's need for clear explanations. Option 2 relies on parents, which may not be as direct or effective. Option 3 dismisses the child's concerns and is nontherapeutic.
During the nurse's shift in the emergency department, a nurse assesses a client who is suspected of being under the influence of opioids. Which symptom is indicative of opioid use?
- A. hypotension
- B. diaphoresis
- C. shallow respirations
- D. outbursts of anger
Correct Answer: C
Rationale: Shallow respirations are a hallmark of opioid intoxication due to respiratory depression.
A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.