Nokea
Which action is best to use initially when trying to help the angry client maintain self-control?
- A. Administer a sedative.
- B. Apply four-point restraints.
- C. Use a calm voice and approach.
- D. Place the client in seclusion.
Correct Answer: C
Rationale: A calm voice and approach de-escalates anger by creating a non-threatening environment, encouraging the client to regain control.
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The nurse is to administer haloperidol 2 mg IV now to the hospitalized client. A vial of haloperidol 5 mg/mL is available. How many milliliters of medication should the nurse administer?____________ mL (Record your answer rounded to the nearest tenth.)
Correct Answer: 0.4
Rationale: Using proportion: 5 mg/1 mL = 2 mg/X mL; 5X = 2; X = 0.4 mL.
When the older client with Alzheimer's disease is confused about how to use a fork, which nursing action is best for prolonging an ability to maintain self-care?
- A. Ask the physician to order a liquid diet.
- B. Position the client to promote mimicking other clients.
- C. See the client first so there is sufficient time to eat.
- D. Seat the client alone so no one will see any mess that occurs.
Correct Answer: B
Rationale: Mimicking others leverages social cues, encouraging independent eating and prolonging self-care abilities.
The client who is addicted to cocaine states “I don’t really need treatment. Things just got a little out of hand causing some problems. I can handle things on my own. I really need to get back to my business.” Which response by the nurse best assists the client to break through denial and get insight into the severity of the addiction?
- A. “Tell me more about the business you feel you must return to at this time.”
- B. “You don’t really need to be here? Tell me more about what you are thinking.”
- C. “You don’t feel you need treatment. How often have you been using cocaine?”
- D. “You say you can handle things but you found yourself with a lot of problems.”
Correct Answer: D
Rationale: Confronting denial with problems (D) builds insight. Business (A) or usage (C) shifts focus parroting (B) risks defensiveness.
Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
The client is admitted to an ED with facial bruises a broken arm and rib fractures. The client states “I fell down the stairs.” During assessment the nurse notes bruises and lacerations in various stages of healing. Which nursing questions are appropriate? Select all that apply.
- A. “Has anyone hurt you?”
- B. “Are you afraid of anyone at home?”
- C. “Have you been falling down a lot lately?”
- D. “Have you had any fainting spells or times that you have been weak?”
- E. “I noticed you have more bruises. Can you tell me how they happened?”
- F. “You look abused. Why haven’t you reported that you have been abused?”
Correct Answer: A ,B ,C ,D, E
Rationale: Appropriate questions explore abuse falls and health issue. Accusing or presuming (F) is insensitive.