Nokea
Which concept is most important for the nurse to convey to a client during a panic attack?
- A. The client is safe.
- B. The client is believed.
- C. The client is cared for.
- D. The client is accepted.
Correct Answer: A
Rationale: Reassuring safety addresses the client's fear, a core component of panic attacks, helping to de-escalate anxiety.
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Which nursing action is the highest priority during the immediate care of a rape victim?
- A. Documenting the circumstances of the rape
- B. Keeping contact with strangers to a minimum
- C. Offering the victim a choice of sedatives
- D. Providing a bath basin, gown, towel, and washcloth
Correct Answer: B
Rationale: Minimizing contact with strangers protects the victim's privacy and reduces distress, prioritizing emotional safety in the immediate aftermath.
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.
Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.
The nurse is assessing the college student who presents with generalized fatigue dry mouth tachycardia and an increased appetite. Which additional finding from the client’s history and physical exam should alert the nurse to explore possible marijuana abuse?
- A. Paranoia
- B. Flashbacks
- C. Gastric disturbances
- D. Conjunctival infection
Correct Answer: D
Rationale: Conjunctival infection (D) is a marijuana sign with fatigue dry mouth tachycardia and appetite increase. Paranoia (A) is methamphetamine flashbacks (B) are hallucinogens gastric issues (C) are alcohol.
When the nurse reviews information about lithium carbonate (Lithane) with the client, which instructions are most important to stress? Select all that apply.
- A. Take a high-potency vitamin each morning.
- B. Refrain from sexual activity while taking this medication.
- C. Notify the physician if urine output increases.
- D. Maintain an adequate intake of sodium and fluids.
- E. Have periodic blood tests to monitor serum levels of the drug.
Correct Answer: C,D,E
Rationale: Monitoring urine output, maintaining sodium/fluid balance, and regular blood tests are critical to prevent lithium toxicity and ensure safe therapy.