Nokea
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 parent expresses concern that her son newly admitted to the mental health unit may be using methamphetamine. Which nursing assessment findings are consistent with methamphetamine abuse?
- A. Hypotension and bradycardia
- B. Constricted pupils and fatigue
- C. Anorexia and recent weight loss
- D. Bruises and scrapes on extremities
Correct Answer: C
Rationale: Anorexia and weight loss (C) are methamphetamine signs. It causes hypertension/tachycardia (A) dilated pupils (B) and bruises (D) are less specific.
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 action is most appropriate if the nurse discovers the oriented older couple having consensual sexual intercourse?
- A. Report it to their adult children.
- B. Restore a measure of privacy.
- C. Suggest they become roommates.
- D. Censure their sexual activity.
Correct Answer: B
Rationale: Restoring privacy respects the couple's autonomy and dignity, supporting their right to consensual intimacy.
Which of the following identified assessment criteria is the highest priority for this client?
- A. The number of characteristics of the client's bowel movements
- B. How much the client knows about colostomy care
- C. Which coping mechanisms the client uses for handling stress
- D. The types of relationships the client has with peers
Correct Answer: A
Rationale: Monitoring bowel movements is critical in ulcerative colitis to assess disease activity and guide treatment, prioritizing physical health.
Which translation method is most beneficial for the client when the nurse obtains the client's history?
- A. A translation card that includes key words, phrases, and pictures
- B. A translator who speaks the client's language
- C. A hospital housekeeper who speaks the client's language
- D. The client's family member who can translate the process
Correct Answer: B
Rationale: A professional translator ensures accurate and confidential communication, critical for obtaining a reliable health history.