Nokea
What is the most appropriate nursing action when the terminally ill client's death is imminent?
- A. Stay with the client and contact the family.
- B. Notify the hospital chaplain of the potential for death.
- C. Call the funeral home, alerting them of an imminent death.
- D. Transfer the client to the intensive care unit.
Correct Answer: A
Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.
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The client states “I don’t see any problem with smoking a little weed. It isn’t addictive.” Which response by the nurse is most accurate?
- A. “Marijuana is a natural chemical that has many therapeutic uses but it is still illegal to use.”
- B. “Marijuana is not addictive. The danger is that it often leads to abuse of more illicit drugs.”
- C. “Marijuana has effects similar to alcohol hallucinogens and sedatives that are addictive.”
- D. “There are no withdrawal symptoms so it is controversial whether marijuana is addictive.”
Correct Answer: C
Rationale: Marijuana’s addictive effects mimic CNS depressants and hallucinogens (C). It’s addictive with withdrawal (D) not just a gateway (B) and legality (A) is irrelevant.
The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?
- A. Allow the parent to enter the room and see the child.
- B. Tell the parent that the HCP wants to speak with the parent first.
- C. Contact Social Services to report the parent’s abusive behavior.
- D. Initiate the emergency response system for behavioral situations.
Correct Answer: D
Rationale: Initiating the emergency response (D) ensures safety. Allowing entry (A) deferring to HCP (B) or reporting to Social Services (C likely already done) are inappropriate.
Which nursing actions will best protect the client's safety? Select all that apply.
- A. Station a security guard outside the client's room at all times.
- B. Remove all cords, wires, and strings in the room.
- C. Provide paper dishes and plastic utensils.
- D. Assess whether the client has swallowed all medications.
- E. Ask a family member to stay with the client during the night.
- F. Check in on the client every 30 minutes.
Correct Answer: B,C,D,F
Rationale: Removing potential hazards, using safe utensils, ensuring medication compliance, and frequent checks minimize suicide risk by reducing means and monitoring behavior.
If a client with chronic mental illness develops the following symptoms after the physician discontinues haloperidol, which one is most likely a consequence of the drug therapy?
- A. Facial tics
- B. Depression
- C. Patchy hair loss
- D. Daytime lethargy
Correct Answer: A
Rationale: Facial tics are a potential tardive dyskinesia symptom, a known side effect of long-term haloperidol use.
When the counselor asks the members of the post-traumatic stress disorder (PTSD) support group to draw pictures of their traumatic experiences, the nurse understands that the primary purpose for drawing is to achieve what outcome?
- A. Deal consciously with painful memories
- B. Bond with other group members
- C. Receive approval from group members
- D. Justify participation in the group
Correct Answer: A
Rationale: Drawing traumatic experiences externalizes memories, helping clients confront and process painful events in a controlled, therapeutic way.