Nokea
What is the best approach for reorienting a confused client who wanders into other clients' rooms?
- A. Place a large sign with the client's name on the door.
- B. Keep the room doors on the unit locked at all times.
- C. Restrain the client in a wheelchair when unattended.
- D. Speak to the client about invading other people's privacy.
Correct Answer: C
Rationale: Restraining in a wheelchair prevents wandering while respecting dignity, though it must be used cautiously and per protocol.
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Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
The client with a history of poly substance abuse is being medically detoxified in an acute care hospital. The client reported recently using alcohol oxycodone crack cocaine and marijuana. In planning for detoxification which substance for detoxification should be the nurse’s priority?
- A. Alcohol
- B. Marijuana
- C. Oxycodone
- D. Crack cocaine
Correct Answer: A
Rationale: Alcohol (A) has the most severe potentially fatal withdrawal. Marijuana (B) oxycodone (C) and cocaine (D) are less life-threatening.
The nurse is in the working phase of a relationship with the client being treated for substance abuse. Which intervention would be appropriate during this phase of treatment?
- A. Assessing the client’s readiness to change substance-abusing behavior
- B. Evaluating the effectiveness of the client’s newly adapted coping skills
- C. Confronting the client’s denial that substances have negatively impacted daily life
- D. Determining the extent to which substances have impaired the client’s functioning
Correct Answer: C
Rationale: Confronting denial (C) is key in the working phase. Readiness (A) and impairment (D) are assessment phase evaluation (B) is final phase.
The client who is addicted to cocaine states “I don’t really need treatment. Things just got a little out of hand causing some problems. I can handle things on my own. I really need to get back to my business.” Which response by the nurse best assists the client to break through denial and get insight into the severity of the addiction?
- A. “Tell me more about the business you feel you must return to at this time.”
- B. “You don’t really need to be here? Tell me more about what you are thinking.”
- C. “You don’t feel you need treatment. How often have you been using cocaine?”
- D. “You say you can handle things but you found yourself with a lot of problems.”
Correct Answer: D
Rationale: Confronting denial with problems (D) builds insight. Business (A) or usage (C) shifts focus parroting (B) risks defensiveness.
The nurse is to administer haloperidol 2 mg IV now to the hospitalized client. A vial of haloperidol 5 mg/mL is available. How many milliliters of medication should the nurse administer?____________ mL (Record your answer rounded to the nearest tenth.)
Correct Answer: 0.4
Rationale: Using proportion: 5 mg/1 mL = 2 mg/X mL; 5X = 2; X = 0.4 mL.