Nokea
Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
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A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
- A. Decreased auditory and visual acuity
- B. Decreased display of emotions
- C. Personality traits that are opposite of original traits
- D. Forgetfulness gradually progressing to disorientation
Correct Answer: D
Rationale: Dementia typically presents with progressive forgetfulness and eventual disorientation.
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
- A. The client runs 4 miles outdoors every afternoon.
- B. The client drinks 2 liters of liquids daily.
- C. The client eats 2-3 grams of sodium-containing foods daily.
- D. The client eats foods high in tyramine.
Correct Answer: A
Rationale: The correct answer is A. Running 4 miles daily causes excessive sweating, leading to dehydration and potential lithium toxicity. Lithium is excreted through the kidneys and dehydration can decrease kidney function, causing lithium levels to rise. Choices B and C are actually helpful as adequate hydration and normal sodium intake reduce the risk of lithium toxicity. Choice D is irrelevant as tyramine is not linked to lithium toxicity.
A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. "I am responsible for my alcoholism."
- B. "I need to identify things that cause me to be an alcoholic."
- C. "I am powerless against my addiction to alcohol."
- D. "I need to see a counselor who will be responsible for my recovery."
Correct Answer: C
Rationale: AA is based on the principle of acknowledging powerlessness over addiction and seeking support.
A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Amenorrhea
- B. Verbalized desire to gain weight
- C. Altered body image
- D. Hyperactivity
- E. Bradycardia
Correct Answer: A, C, D, E
Rationale: Anorexia nervosa is often associated with amenorrhea, distorted body image, excessive activity, and bradycardia due to malnutrition.
A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
- A. "Because you are a minor, I have to share any information that I feel is important with your parents."
- B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
- C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
- D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
Correct Answer: B
Rationale: Duty to warn applies when a client expresses intent to harm others, requiring disclosure to the care team.