Nokea
Which approach is best for managing the client's care?
- A. Use a nonjudgmental manner when cleaning the client of stool.
- B. Ask the client's spouse to perform hygiene measures.
- C. Hold the client responsible for all hygiene.
- D. Assign same-gender nurses to care for the client.
Correct Answer: A
Rationale: A nonjudgmental approach preserves the client's dignity, reducing embarrassment and supporting self-esteem during hygiene care.
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Which findings strongly suggest that the client is experiencing an exacerbation of the bipolar disorder? Select all that apply.
- A. The client has been spending money extravagantly.
- B. The client has been avoiding social activities.
- C. The client has been methodically cleaning the house.
- D. The client has been staying up late to read.
- E. The client demonstrates increased sexual promiscuity.
- F. The client has increased anxiety when going outside the house.
Correct Answer: A,E
Rationale: Extravagant spending and sexual promiscuity are indicative of mania, a key feature of bipolar disorder exacerbation.
The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?
- A. Allow the parent to enter the room and see the child.
- B. Tell the parent that the HCP wants to speak with the parent first.
- C. Contact Social Services to report the parent’s abusive behavior.
- D. Initiate the emergency response system for behavioral situations.
Correct Answer: D
Rationale: Initiating the emergency response (D) ensures safety. Allowing entry (A) deferring to HCP (B) or reporting to Social Services (C likely already done) are inappropriate.
The client uses methamphetamine regularly. Which subjective quote documented by the nurse demonstrates the client using pathological projection as a coping mechanism?
- A. “I’m here to get help. Everything will be all right again if I can just stop using drugs.”
- B. “My dad and I don’t get along. He thinks that I’m a failure and can’t do anything right.”
- C. “I’m not giving up alcohol just the methamphetamine. I never had a problem with alcohol.”
- D. “I can’t go back to work. I’d be so embarrassed if anyone found out I’ve been in treatment.”
Correct Answer: B
Rationale: Blaming dad for failure (B) is projection. Simplifying issues (A) is ignoring dismissing alcohol (C) is denial embarrassment (D) is perfectionism.
If the client snorts cocaine on a regular basis, which physical assessment findings will the nurse most likely find? Select all that apply.
- A. Dry, stuffy nose
- B. Perforated nasal septum
- C. Hoarseness and cough
- D. Sinus pain under the eyes
- E. Elevated blood pressure
- F. Inability to sleep
Correct Answer: A,B,D,E,F
Rationale: Regular cocaine snorting causes nasal irritation, septal damage, sinus pain, hypertension, and insomnia due to its stimulant effects.
If the physician prescribes imipramine hydrochloride (Tofranil) for the client, the nurse should assess for which therapeutic drug effect first?
- A. Absence of suicidal ideation
- B. Improved concentration
- C. Decreased agitation
- D. Regulated mood
Correct Answer: D
Rationale: Regulated mood is the primary therapeutic effect of imipramine, addressing the core symptoms of depression.