Nokea
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status
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The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:
- A. Changes in gait
- B. Loss of concentration
- C. Problems with speech
- D. Seizures
Correct Answer: B
Rationale: Loss of concentration is an early cognitive change in AIDS dementia complex.
A manic client is admitted to an inpatient psychiatric center. He is hyperactive, talking quickly, acting aggressively, and pacing. The nursing staff should
- A. outline realistic expectations for the client's behavior.
- B. ignore the client's behavior.
- C. allow the client to eat lunch with other clients to observe the interaction.
- D. assign an RN to stay with the client at all times.
Correct Answer: D
Rationale: A manic client’s behavior requires close supervision for safety. Assigning an RN to stay with the client ensures monitoring and intervention as needed.
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
- A. Chronic fatigue syndrome
- B. Normal aging
- C. Sundowning
- D. Delusions
Correct Answer: C
Rationale: Sundowning is a common phenomenon in dementia where confusion worsens in the late afternoon and evening.
The nurse is assessing a client with suspected diverticulitis. Which of the following findings would the nurse expect?
- A. Pain in the right upper quadrant.
- B. Fever and left lower quadrant pain.
- C. Diarrhea with bright red blood.
- D. Soft, non-tender abdomen.
Correct Answer: B
Rationale: fever and left lower quadrant pain are common in diverticulitis due to inflammation in the sigmoid colon
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order
- B. Administer the medications
- C. Administer separately
- D. Contact the pharmacy
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly used together for hypertension, as they have complementary effects, so administering them is appropriate.