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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What nursing approach is most beneficial for helping the nursing assistant at this time?
- A. Sending the nursing assistant home for the rest of the shift
- B. Terminating the nursing assistant from this type of work
- C. Allowing the nursing assistant to express feelings
- D. Asking the nursing assistant to help with postmortem care
Correct Answer: C
Rationale: Allowing expression of feelings helps the assistant process grief, supporting emotional well-being after a distressing event.
The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?
- A. Assist the client in regaining self-control
- B. Assure the safety of the client and others
- C. Regain control over the unit’s environment
- D. Provide a consequence for the client’s behavior
Correct Answer: B
Rationale: Safety of client and others (B) is the primary seclusion goal by reducing stimuli. Self-control (A) and unit control (C) are outcomes and punishment (D) is inappropriate.
Which statement is most important for the nurse to convey to the parents after they have been informed of their infant?
- A. We did all we could to resuscitate your baby.
- B. The baby would have been brain damaged had he lived.
- C. You did not cause, nor could you have prevented, your baby's death.
- D. Grief support groups are available for situations such as yours.
Correct Answer: C
Rationale: Reassuring parents that they are not responsible alleviates potential guilt, addressing a critical emotional need during acute grief.
The client is receiving clonidine to relieve selected symptoms of opioid withdrawal. Which assessment is most important for the nurse to complete before administering clonidine?
- A. Check for presence of dilated pupils
- B. Investigate recent nausea or vomiting
- C. Test for abnormally heightened reflexes
- D. Verify that the blood pressure is not low
Correct Answer: D
Rationale: Clonidine requires BP check (D) to avoid hypotension. Dilated pupils (A) nausea (B) and reflexes (C) don’t contraindicate it.
Which recommendation by the nurse is most likely to be effective in helping the client control bulimia?
- A. Eat small, frequent meals.
- B. Take a daily inventory of food offered at the dormitory.
- C. Avoid eating in fast food establishments.
- D. Keep a daily calorie count of all foods consumed.
Correct Answer: A
Rationale: Small, frequent meals stabilize eating patterns, reducing the urge to binge and purge, a key strategy in managing bulimia.