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When a new member to the group tells the nursing leader about sensing the presence of the dead spouse in the home, which nursing intervention is most appropriate?
- A. Recommending more professional counseling
- B. Assuring the client that it is wishful thinking
- C. Listening quietly and acknowledging the client's feelings
- D. Encouraging the client to stay with relatives
Correct Answer: C
Rationale: Listening and acknowledging feelings validates the client's experience, supporting grief processing in a therapeutic manner.
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In this situation, which nursing action is most appropriate?
- A. Placing restraints on the client's arms and legs
- B. Reassuring the client that the bugs are imaginary
- C. Reporting the behavior to the doctor to obtain a sedative order
- D. Closing the client's door so that others are not alarmed
Correct Answer: C
Rationale: Reporting delirium tremens symptoms, like hallucinations, to the physician ensures timely medical intervention for alcohol withdrawal.
Which therapeutic activity is most helpful in facilitating reminiscence therapy among older adult clients?
- A. Discussing a current event topic
- B. Singing popular songs from the 1960s
- C. Reading an article from the newspaper
- D. Making decorations for a future holiday
Correct Answer: B
Rationale: Singing familiar songs from the past stimulates memories, enhancing engagement in reminiscence therapy.
Which of the following verbal communication methods is best to use with a client with dementia?
- A. Speak loudly to get the client's attention.
- B. Use short sentences when speaking to the client.
- C. Use written forms of communication.
- D. Allow the client to listen to news programs.
Correct Answer: B
Rationale: Short sentences are easier for dementia clients to process, enhancing comprehension and reducing frustration.
If the nurse documents all of the following information in the database, which finding is probably the most significant source of conflict and anxiety for this client?
- A. The client is facing forced retirement.
- B. The client has 12 grandchildren.
- C. The client is learning to use a computer.
- D. The client wants to sell the family home.
Correct Answer: A
Rationale: Forced retirement is a major life transition that can cause significant stress and anxiety due to loss of role and identity.
The client is visibly upset pounding on the desk at the nurses’ station and shouting “You’re the nurse so you have to fix this now.” What should be the nurse’s primary rationale for recognizing that the client is a danger to staff and other clients?
- A. The client is verbally threatening the nurse to fix the situation now.
- B. The client does not acknowledge his or her role in the problem-solving process.
- C. The client has no apparent ability to recognize that he or she is acting inappropriately.
- D. The client’s main strategy for meeting personal needs and wants is intimidation and anger.
Correct Answer: D
Rationale: Intimidation and anger as primary strategies (D) indicate danger. No verbal threat (A) role acknowledgment (B) or recognition of inappropriateness (C) is evident.