Nokea
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.
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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).
The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?
- A. The client’s own private room down the hall
- B. The unit’s common television dayroom
- C. An outdoor sheltered client smoking area
- D. An out-of-the-way corner near the nursing station
Correct Answer: D
Rationale: A quiet visible corner near the station (D) aids de-escalation. Private rooms (A) and outdoor areas (C) lack visibility and the dayroom (B) is too stimulating.
Staff are debriefing following the client’s violent episode. Which information should be included in the debriefing session? Select all that apply.
- A. Client’s coping mechanisms post-event
- B. The client’s history of violent behavior
- C. Adherence to instructional policies and procedures
- D. Staff’s feelings regarding the effectiveness of the team
- E. Staff’s ability to respond to the client therapeutically post-event
Correct Answer: C ,D, E
Rationale: Debriefing includes policy adherence (C) team effectiveness (D) and therapeutic response (E) to identify training needs. Client coping (A) and history (B) are not debriefing focuses.
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.
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.