Nokea
When the anxious client summons the nurse and reports feeling weak and dizzy, which nursing action is most appropriate at this time?
- A. Helping the client to relax
- B. Giving the client something to eat
- C. Administering oxygen by cannula
- D. Taking the client's vital signs
Correct Answer: D
Rationale: Taking vital signs assesses for physiological causes of weakness and dizziness, ensuring appropriate intervention for the anxious client.
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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.
Which question during the client interview is likely to generate the most information?
- A. Tell me about your family.
- B. Are you currently married?
- C. Who is your nearest relative?
- D. Give me a list of your family members.
Correct Answer: A
Rationale: An open-ended question about family prompts detailed responses, providing comprehensive insight into social support and history.
The client is experiencing withdrawal symptoms leading to sleep deprivation. The nurse should recognize that the client is at greatest risk for violent behavior due to which assessment finding?
- A. Poor coping mechanisms
- B. Physical pain from withdrawal
- C. A sense of guilt/shame regarding family
- D. Anxiety over lack of access to the substance of choice.
Correct Answer: D
Rationale: Anxiety from lack of substance access (D) is the primary violence risk in withdrawal. Poor coping (A) pain (B) and guilt (C) are secondary contributors.
The client with Alzheimer’s disease becomes increasingly agitated and states “I must go and clean out the barn!” Which nursing response is most therapeutic?
- A. “What makes you think that the barn needs to be cleaned?”
- B. “So you’ve cleaned a barn. Tell me did you live on a farm?”
- C. “It’s awfully hot today; maybe you should wait until tomorrow.”
- D. “There are no barns around here. Would you like something to eat?”
Correct Answer: B
Rationale: Redirecting to memories (B) calms agitation without confrontation. Asking why (A) or stating facts (D) may escalate and delaying (C) blocks communication.
The nurse explains to the client's family the alcoholic's recovery process. What is the first step in recovering from alcohol?
- A. Admitting an inability to control drinking
- B. Forming a close support network
- C. Relying on some form of religious belief
- D. Checking into an inpatient rehabilitation unit
Correct Answer: A
Rationale: Admitting powerlessness over alcohol is the foundational step in recovery models like Alcoholics Anonymous, as it acknowledges the problem and initiates the commitment to change.