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Which form of instruction is most beneficial when preparing the anxious client?
- A. Provide detailed explanations.
- B. Use short, simple sentences.
- C. Draw elaborate diagrams.
- D. Show a teaching DVD.
Correct Answer: B
Rationale: Short, simple sentences are easier for an anxious client to process, reducing cognitive overload and improving comprehension.
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If the older adult's sons and daughters are visiting on the day of the scheduled nurse's visit, which action is most appropriate before beginning the assessment?
- A. Encourage the client's children to offer their comments at any time.
- B. Provide a private setting for conducting the assessment.
- C. Identify the names and relationships of those present.
- D. Offer to share the assessment results with the client's children.
Correct Answer: B
Rationale: A private setting ensures confidentiality and encourages honest responses, critical for an accurate health assessment.
When a 24-year-old with a record of multiple convictions for driving under the influence (DUI) claims not to be an alcoholic, which is the most pertinent assessment question the nurse can ask?
- A. When you drink, do you drink beer or hard liquor?
- B. Did you begin drinking before or after you were of legal age?
- C. Do you prefer to drink alcohol rather than soft drinks?
- D. Are you unable to recall events that occurred while drinking?
Correct Answer: D
Rationale: Asking about memory loss during drinking episodes assesses for blackouts, a key indicator of problematic drinking patterns associated with alcoholism.
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 preparing to document the client’s violent episode. Which statements should be included specifically about the violent episode? Select all that apply.
- A. Client’s wife called during the escalation cycle.
- B. Client refused to voluntarily enter into seclusion.
- C. Client stated “All of you are just evil people.”
- D. Attempts to identify the cause of client’s agitation failed.
- E. Five staff members responded to “Emergency Code.”
- F. Client asked to leave seclusion room after 30 minutes.
Correct Answer: B ,C, D, F
Rationale: Documentation includes refusal of seclusion (B) client statements (C) failed interventions (D) and reintegration (F). Wife’s call (A) and staff numbers (E) are irrelevant.
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.