Nokea
Which assessment finding is most atypical of a 65-year-old client?
- A. Making errors in copying a line drawing
- B. Forgetting the names of longstanding neighbors
- C. Reading information slowly
- D. Naming only two of the last three presidents
Correct Answer: A
Rationale: Errors in copying a drawing suggest visuospatial deficits, less common in typical aging and more indicative of neurological issues.
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The spouse of the client who is currently in inpatient treatment for substance abuse tells the nurse “We’ve done this so many times. I don’t think my spouse is ever going to change. Do you think it’s time for me to get a divorce?” Which response by the nurse is most helpful?
- A. “You don’t think your spouse is ever going to change?”
- B. “Sounds like you’re feeling discouraged in your marriage.”
- C. “Your spouse will likely continue to use and need treatment again.”
- D. “That’s your decision; I can’t tell you whether you should get a divorce.”
Correct Answer: B
Rationale: Validating discouragement (B) encourages exploration. Restatement (A) is less effective predicting relapse (C) is opinionated and dismissing (D) closes communication.
The older disheveled client is admitted to the ED with hypertension severe dehydration and malnourishment. During the admission interview the daughter notes that she and her husband who is temporarily out of work have been living with the client. Which nursing action is most important?
- A. Report the suspected elder abuse to Adult Health Protective Services.
- B. Ask additional questions of the client in private without the family present.
- C. Ask the daughter whether her father has been eating and taking his medication.
- D. Call the resource hotline to ask whether abuse and neglect should be considered.
Correct Answer: B
Rationale: Private questioning (B) elicits abuse/neglect details. Reporting (A) needs more evidence asking the daughter (C) is less direct and calling a hotline (D) is secondary.
The nurse observes that the client diagnosed with intermittent explosive disorder is becoming aggressive and that lorazepam was prescribed. The client is now exhibiting a tense posture a clenched fist and a defiant affect. Prioritize the nurse’s actions to de-escalate the client’s aggression.
- A. Call other staff for assistance.
- B. Attempt to talk the client down.
- C. Apply wrist restraints.
- D. Offer client choice of taking medication voluntarily.
- E. Provide alternate use of physical energy such as suggesting punching a pillow.
Correct Answer: B ,E ,D ,A, C
Rationale: Talk down (B) builds trust offering physical outlets (E) releases tension medication choice (D) calms staff assistance (A) ensures safety and restraints (C) are last resort for harm prevention.
The nurse is developing the plan of care for the client diagnosed with schizophrenia who is having an alcohol-induced crisis. Which specific client outcome best reflects the primary goal of crisis intervention for this client?
- A. Client will be successfully detoxified within 20 days.
- B. Client will return to his or her part-time job within 20 days.
- C. Client will state two effective coping mechanisms prior to discharge.
- D. Client will demonstrate self-administration of medications prior to discharge.
Correct Answer: B
Rationale: Returning to pre-crisis functioning like work (B) is the crisis intervention goal. Detox (A) stating coping mechanisms (C) and medication administration (D) are secondary.
The nurse counsels the team member privately about the inappropriate remark. What is the first step in understanding the behavior of clients?
- A. Understanding one's own behavior
- B. Analyzing what motivates clients' behavior
- C. Becoming more familiar with abnormal behavior
- D. Taking courses in counseling
Correct Answer: A
Rationale: Self-awareness of personal biases is the first step to understanding client behavior, ensuring objective and empathetic care.