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What nursing approach is most beneficial for helping the nursing assistant at this time?
- A. Sending the nursing assistant home for the rest of the shift
- B. Terminating the nursing assistant from this type of work
- C. Allowing the nursing assistant to express feelings
- D. Asking the nursing assistant to help with postmortem care
Correct Answer: C
Rationale: Allowing expression of feelings helps the assistant process grief, supporting emotional well-being after a distressing event.
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Which finding noted by the nurse during the postoperative assessment is most indicative of the client's alcoholism?
- A. Blood pressure is lower than normal.
- B. Pain is unrelieved with usual dosages of analgesics.
- C. The client asks for a beer.
- D. Pulse rates are slow, weak, and irregular.
Correct Answer: B
Rationale: Alcoholism can lead to tolerance, requiring higher analgesic doses for pain relief due to altered liver metabolism and receptor sensitivity.
Which statement is most important for the nurse to convey to the parents after they have been informed of their infant?
- A. We did all we could to resuscitate your baby.
- B. The baby would have been brain damaged had he lived.
- C. You did not cause, nor could you have prevented, your baby's death.
- D. Grief support groups are available for situations such as yours.
Correct Answer: C
Rationale: Reassuring parents that they are not responsible alleviates potential guilt, addressing a critical emotional need during acute grief.
Which recommendation by the nurse is most likely to be effective in helping the client control bulimia?
- A. Eat small, frequent meals.
- B. Take a daily inventory of food offered at the dormitory.
- C. Avoid eating in fast food establishments.
- D. Keep a daily calorie count of all foods consumed.
Correct Answer: A
Rationale: Small, frequent meals stabilize eating patterns, reducing the urge to binge and purge, a key strategy in managing bulimia.
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
Which explanation by the nurse is most accurate?
- A. The client was frightened of them as a child.
- B. The client is frightened of being injured.
- C. The client associates the sound of the fireworks with gunfire.
- D. The client is afraid it will trigger memories.
Correct Answer: C
Rationale: The veteran's startled reaction likely stems from associating fireworks with gunfire, a common PTSD trigger due to past combat exposure.