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Which action by the client is most suggestive of denial about the illness?
- A. The client conceals the information from family members.
- B. The client avoids contact with homosexual friends.
- C. The client responds to the former group of the nurse.
- D. The client has intercourse without using condoms.
Correct Answer: D
Rationale: Engaging in unprotected intercourse indicates denial of the HIV diagnosis, as it disregards the risk of transmission and personal health implications.
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The nurse suspects that a coworker is working while impaired. Which initial action should be taken by the nurse?
- A. Contact the Drug Enforcement Agency (DEA).
- B. Contact the nurse manager to report the incident.
- C. Confront the nurse and suggest that the nurse “get help.”
- D. File an anonymous report with the state’s board of nursing.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) initiates investigation. DEA (A) is for diversion confronting (C) risks denial board reporting (D) follows manager.
The nurse observes that the client diagnosed with intermittent explosive disorder is becoming aggressive and that lorazepam was prescribed. The client is now exhibiting a tense posture a clenched fist and a defiant affect. Prioritize the nurse’s actions to de-escalate the client’s aggression.
- A. Call other staff for assistance.
- B. Attempt to talk the client down.
- C. Apply wrist restraints.
- D. Offer client choice of taking medication voluntarily.
- E. Provide alternate use of physical energy such as suggesting punching a pillow.
Correct Answer: B ,E ,D ,A, C
Rationale: Talk down (B) builds trust offering physical outlets (E) releases tension medication choice (D) calms staff assistance (A) ensures safety and restraints (C) are last resort for harm prevention.
The indigent client with both emotional and physical diagnoses has just attended a discharge planning session with the nurse. Which client behavior shows the greatest commitment to the client’s self-management?
- A. Correctly stating the medications prescribed and the administration schedule
- B. Asking to stay with a relative until an affordable place to live can be found
- C. Researching the names of and calling contact people at local support centers
- D. Promising the nurse to keep the scheduled follow-up appointments at the clinic
Correct Answer: C
Rationale: Calling support centers (C) shows proactive engagement. Stating medications (A) seeking housing (B) and promising appointments (D) are less indicative of commitment.
Which response by the nurse is most accurate?
- A. It will show up in urine tests 3 to 4 days after use.
- B. Traces may be picked up by sensitive blood tests 8 to 10 weeks later.
- C. Hair analysis can detect marijuana use more than a year before the urine test.
- D. Marijuana leaves the body within 2 hours of smoking it.
Correct Answer: B
Rationale: Marijuana metabolites can be detected in blood tests for weeks, with sensitive tests picking up traces 8 to 10 weeks after use, depending on frequency and amount used.
When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.