Nokea
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?
- A. Spend time sitting in silence with the client.
- B. Involve the client in a daily exercise program.
- C. Ask the client to describe her depression.
- D. Observe for signs of possible psychosis.
Correct Answer: A
Rationale: Spending time in silence creates a supportive environment, allowing the client to communicate at her pace, addressing delayed responses.
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History and Physical
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. Nurses' Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.
- A. The client discusses moving to Hawaii instead of returning to rebuild her house. (Fantasy)
- B. The client seems unemotional when talking about needing to rebuild her house. (Isolation)
- C. The client states that she sometimes forgets why she is in the hospital. (Suppression)
- D. The client is frightened that the hospital will burn down. (Denial)
Correct Answer: A,B,C,D
Rationale: Fantasy (Hawaii move) escapes reality, isolation (unemotional) separates emotions, suppression (forgetting hospitalization) avoids distress, and denial (hospital fire fear) projects trauma.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.
- C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.
- D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.
Correct Answer: C
Rationale: Close monitoring and intervention are critical to prevent self-harm in a client showing signs of distress, prioritizing safety.
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
- A. Postpone the client interview until the next day.
- B. Document the client's paranoid behavior.
- C. Attempt to ask the client simple questions.
- D. Ask another nurse to talk with the client.
Correct Answer: C
Rationale: Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish rapport. Postponing delays care, documenting should follow engagement, and involving another nurse is a later option.
Laboratory Results
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and was not able to go for her scheduled dialysis 2
What treatments should the nurse anticipate for the client at this time? Select all that apply.
- A. Call and give a report immediately
- B. Administer loop diuretic
- C. Schedule for Hemodialysis immediately
- D. Check blood glucose level
- E. Draw a repeat potassium level
- F. Hold Lisinopril
- G. Administer insulin, dextrose 50%, and calcium gluconate. Then repeat 12 lead EKG
Correct Answer: C,D,E,F,G
Rationale: Hemodialysis, checking glucose, repeating potassium, holding Lisinopril, and administering insulin/dextrose/calcium gluconate address hyperkalemia and ESRD complications. Loop diuretics are contraindicated, and reporting is not a treatment.
The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap is too harsh for the radiation site, indicating a need for further teaching. Prescribed lotions, protective clothing, and patting to dry are appropriate.