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Which action is most appropriate for the nurse to take first?
- A. Remind the client that clothes are required in public.
- B. Instruct the client to put clothes on again.
- C. Explain to the residents that the client is not of sound mind.
- D. Take the client to a vacant room nearby.
Correct Answer: D
Rationale: Taking the client to a private room ensures dignity and safety, addressing the immediate need without public confrontation.
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The client is started on buprenorphine with naloxone (Suboxone) sublingual for opiate addiction. Which statements indicate that the client understood the nurse’s instructions about the medication? Select all that apply.
- A. “The medication can slow or stop my breathing. I should only take what is prescribed.”
- B. “I’m taking this non habit-forming medication to help stop my craving for opiate drugs.”
- C. “If I suddenly stop taking buprenorphine and naloxone I could experience withdrawal.”
- D. “I can take the tablet whole or crush it and take it with food to make it more palatable.”
- E. “This drug is highly abused; I should not share this or keep it where it can be stolen.”
Correct Answer: A ,C, E
Rationale: Suboxone risks respiratory depression (A) causes withdrawal if stopped (C) and is abusable (E). It’s habit-forming (B) and sublingual tablets shouldn’t be crushed (D).
When resuscitation efforts are unsuccessful, which nursing action is most appropriate?
- A. Ask the parents for permission to perform an autopsy.
- B. Ask about the possibility of harvesting the infant's organs for transplantation.
- C. Check on the parents' choice for the funeral arrangements.
- D. Take the parents to a room where they can be with the baby.
Correct Answer: D
Rationale: Allowing parents to spend time with their deceased infant supports grieving and closure, prioritizing their emotional needs immediately after the loss.
Which therapeutic nursing intervention is most beneficial for a client diagnosed with post-traumatic stress disorder (PTSD)?
- A. Administering antianxiety medications
- B. Monitoring the client's physical symptoms
- C. Encouraging the client to express feelings
- D. Investigating the client's current family interactions
Correct Answer: C
Rationale: Expressing feelings helps process trauma, reducing PTSD symptoms by fostering emotional regulation and insight.
Which nursing assessment is critical to ensuring the client's well-being during the home visit?
- A. The caregiver's understanding of the symptoms the client manifests
- B. The caregiver's understanding of when the client must return
- C. The caregiver's understanding of when to administer medications
- D. The caregiver's understanding of how to provide hygiene measures
Correct Answer: C
Rationale: Proper medication administration is critical for Alzheimer's clients, ensuring symptom management and safety during the visit.
The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?
- A. Call the mental health unit to arrange for inpatient treatment.
- B. Give medications to reverse the effects of the hallucinogenic drug.
- C. Stay with the client to protect the client from self-harm until relieved.
- D. Call hospital security so security staff is present to protect staff from injury.
Correct Answer: C
Rationale: Staying with the client (C) prevents self-harm due to altered perception. Inpatient arrangements (A) reversal drugs (B unavailable) and security (D) are secondary.