Nokea
Which action by the nurse can best determine if an older client's inappropriate responses to several questions are due to miscommunication or to impaired cognition?
- A. Ask the client to repeat the question before answering it.
- B. Ask questions that require only a 'yes' or 'no' response.
- C. Ask the client's next of kin for answers to the questions.
- D. Ask questions to which the client is sure to know the answers.
Correct Answer: A
Rationale: Having the client repeat the question clarifies whether misunderstanding or cognitive impairment caused the inappropriate response.
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Which nursing intervention is most beneficial for the client's spouse at this time?
- A. Suggesting that the spouse make an appointment for a physical examination
- B. Discussing modifying the amount of time the spouse devotes to care-giving
- C. Reminding the spouse of the scheduled times for visiting clients on the unit
- D. Explaining that many staff are available to care for the client
Correct Answer: B
Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.
The client often avoids talking about cocaine use by refocusing on other problems such as losing a job and family discord. Which is the most helpful response by the nurse when the client avoids discussing using cocaine?
- A. “Has your cocaine use helped you to cope with these problems in the past?”
- B. “You need to consider that all these problems are related to your cocaine use.”
- C. “How do you think these problems will change once you no longer use cocaine?”
- D. “You can’t do anything about these while here. Just focus on getting off of cocaine.”
Correct Answer: C
Rationale: Linking drug use to problems (C) builds insight. Coping (A) is inaccurate opinions (B) cause defensiveness and avoiding issues (D) is unhelpful.
Which response by the nurse is best in this situation?
- A. That is something to discuss with your physician.
- B. It sounds like you're feeling discouraged.
- C. But you're about your lack of progress.
- D. You need to practice a little more patience.
Correct Answer: B
Rationale: Acknowledging discouragement validates the client's feelings, fostering therapeutic communication and emotional support.
Which initial reaction would the nurse expect if the client is typical of others who just received news of this diagnosis?
- A. Anger
- B. Shock
- C. Resentment
- D. Depression
Correct Answer: B
Rationale: Shock is the most common initial reaction to an HIV diagnosis, as it reflects the overwhelming and unexpected nature of the news.
The client receiving treatment for substance dependence has not been attending group therapy. Which response by the nurse to confront this behavior is best?
- A. “Why don’t you want to go to group therapy? Other users are there waiting for you to attend.”
- B. “Talking about personal issues with others can be difficult. Try talking to the therapist alone.”
- C. “Therapy is important to your treatment. You need to attend therapy if you want to get better.”
- D. “You say you want to get better but you are not actively participating in your treatment plan.”
Correct Answer: D
Rationale: Confronting nonattendance nonjudgmentally (D) addresses denial. “Why” questions (A) suggesting alternatives (B) or threats (C) are less effective.