Nokea
Which explanation by the nurse is most accurate?
- A. The client was frightened of them as a child.
- B. The client is frightened of being injured.
- C. The client associates the sound of the fireworks with gunfire.
- D. The client is afraid it will trigger memories.
Correct Answer: C
Rationale: The veteran's startled reaction likely stems from associating fireworks with gunfire, a common PTSD trigger due to past combat exposure.
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Which of the following instructions are appropriate to include in the teaching plan of a client who is just beginning treatment with imipramine hydrochloride (Tofranil)? Select all that apply.
- A. Avoid tyramine-rich foods such as aged cheese and pickled foods.
- B. Take short naps during the day.
- C. Rise from the chair or bed slowly.
- D. Expect to wait about 3 weeks before feeling better.
- E. Refrain from all sexual activity for 1 month after starting the medication.
- F. Use a good sunscreen when outdoors.
Correct Answer: A,C,D
Rationale: Avoiding tyramine prevents hypertensive crisis, slow rising reduces orthostatic hypotension, and delayed effects set realistic expectations.
The nurse is interacting with the client who abuses methamphetamine. The client states “I don’t plan to quit meth. I can work for days when I’m high.” Which is the best response by the nurse?
- A. “You’ll exhaust yourself working days when you’re high.”
- B. “You can’t see the real problem yet because you’re in denial.”
- C. “You say you don’t plan to quit. Do you think using drugs helps you?”
- D. “Good point. You probably do work long hours while you are on meth.”
Correct Answer: C
Rationale: Restating neutrally (C) encourages reexamination. Directives (A) labeling denial (B) or agreeing (D) are less effective.
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
Which technique is best for reducing confusion among clients with dementia?
- A. Wear an employee name tag when caring for clients.
- B. Adhere to a consistent routine of unit activities.
- C. Provide diversional activities such as field trips.
- D. Distribute a list of the day's scheduled events.
Correct Answer: B
Rationale: A consistent routine minimizes confusion by providing predictability, supporting cognitive stability in dementia.
The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client’s readiness to leave involuntary seclusion?
- A. The client calmly stating “I have control over my anger now.”
- B. BP is 110/64 mm Hg; P is 82 bpm and regular; R is 16 bpm and regular.
- C. Client is observed sitting in seclusion room doorway asking staff for a drink.
- D. Medical record states “Seclusion of 45 minutes resulted in improved control.”
Correct Answer: C
Rationale: Sitting in the doorway and requesting a drink (C) shows tolerance to stimuli. Statements (A) vital signs (B) and records (D) are less definitive than observed behavior.