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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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Which nursing action is especially important when administering medications to a depressed client?
- A. Encouraging the client to drink a full glass of water
- B. Checking that the client has swallowed all oral medications
- C. Giving the medications on an empty stomach before meals
- D. Having the client take each medication separately
Correct Answer: B
Rationale: Ensuring medications are swallowed prevents hoarding, a risk in depressed clients with suicidal ideation.
The nurse is teaching home health aides about monitoring for alcohol abuse in older adults. Which response by a home health aide indicates a need for further teaching?
- A. “Alcohol abuse is the largest category of substance abuse problems in older adults.”
- B. “I should monitor more closely for alcohol abuse in single male clients who smoke.”
- C. “Retirement and freedom from work and family pressures tend to decrease alcohol use.”
- D. “Confusion malnutrition and self-neglect may be signs of alcohol abuse in the elderly.”
Correct Answer: C
Rationale: Retirement can increase alcohol use due to isolation (C is incorrect). Alcohol is a major issue (A) risk factors include male smokers (B) and signs include confusion (D).
If the client has been taking an antidepressant for several weeks, which outcome would be the most desired therapeutic effect?
- A. The client is feeling less depressed.
- B. The client is eating more nutritiously.
- C. The client is having fewer food binges.
- D. The client is feeling less suicidal.
Correct Answer: C
Rationale: Reducing binge episodes is the primary goal for bulimia treatment, as antidepressants target the compulsive behaviors associated with the disorder.
Which nursing action is most appropriate for determining whether domestic abuse is occurring?
- A. Ask directly if domestic abuse is occurring.
- B. Arrange a second visit to validate suspicions.
- C. Assess the young children for signs of injury.
- D. Make inquiries among relatives or neighbors.
Correct Answer: A
Rationale: Directly asking about abuse in a safe, private setting encourages honest disclosure and is the most effective initial step to confirm suspicions.
The nurse is caring for the client who has methamphetamine toxicity. Which interventions should the nurse include in the client’s plan of care? Select all that apply.
- A. Give olanzapine 10 mg IM q2h prn to treat agitation.
- B. Allow the client to sleep and eat as much as desired.
- C. Administer labetalol 20 mg IV to control hallucinations.
- D. Monitor 1:1 to protect client from harm to self and others.
- E. Encourage involvement in the therapeutic treatment milieu.
Correct Answer: A ,B ,D
Rationale: Olanzapine (A) reduces agitation sleep/eating (B) aids recovery 1:1 monitoring (D) ensures safety. Labetalol (C) is for BP not hallucinations; milieu (E) is premature.