Nokea
The nurses critique a chart entry that says, 'States, I feel unwanted." Appears to be confused.' Which statement best describes why this entry is unsatisfactory?"
- A. The nurse who made the entry failed to interpret the significance of feeling unwanted.
- B. The nurse who made the entry failed to indicate the importance of the client's statement.
- C. The nurse who made the entry failed to substantiate that the client made the quote.
- D. The nurse who made the entry failed to describe the evidence of the confused behavior.
Correct Answer: D
Rationale: Failing to describe specific behaviors supporting 'confused' makes the entry vague, reducing its clinical usefulness.
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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 new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement made by the new nurse reflects an immediate need for follow-up by the mentor?
- A. “My first concern is the safety of all those on the unit.”
- B. “I know to turn off the television when the client starts pacing the floor.”
- C. “When the client started getting aggressive I tried talking the client down.”
- D. “I’m going to try and assign the same staff to work with the client each shift.”
Correct Answer: C
Rationale: Talking during aggression (C) adds stimuli and requires mentor follow-up. Safety focus (A) reducing stimuli (B) and consistent staff (D) are appropriate.
The NA is helping the ED nurse admit a woman who is the victim of spousal abuse and marital rape. The NA asks the nurse what should be done with the woman’s torn and soiled clothing. What is the nurse’s best response?
- A. “Place items in a plastic bag and avoid blood and body fluid contact.”
- B. “Ask the woman what she wants done with her clothing; she may want them discarded.”
- C. “These may be needed by the police. I will remove them and place in separate paper bags.”
- D. “Fold each article of clothing and leave them with her; she can decide later about disposal.”
Correct Answer: C
Rationale: Placing clothing in paper bags (C) preserves evidence for police. Plastic bags (A) cause mold asking the victim (B) or leaving with her (D) risks evidence loss.
Which response by the nurse is best in this situation?
- A. That is something to discuss with your physician.
- B. It sounds like you're feeling discouraged.
- C. But you're about your lack of progress.
- D. You need to practice a little more patience.
Correct Answer: B
Rationale: Acknowledging discouragement validates the client's feelings, fostering therapeutic communication and emotional support.
The nurse correctly informs the caller that most people have which physical signs after recent marijuana use? Select all that apply.
- A. Shivering
- B. Inflamed eyes
- C. Rapid pulse
- D. Restlessness
- E. Pinpoint pupils
- F. Increased sex drive
Correct Answer: B,C,D
Rationale: Recent marijuana use commonly causes inflamed (red) eyes due to vasodilation, rapid pulse from cardiovascular stimulation, and restlessness from its psychoactive effects.