Nokea
Which nursing action is most appropriate at this time?
- A. Criticize the nature of the client's rude behavior.
- B. Support the emaciated client who was targeted by the remark.
- C. Invite others in the group to respond to the situation.
- D. Embarrass the bulimic client with a similar comment.
Correct Answer: B
Rationale: Supporting the targeted client validates their feelings and maintains a safe group environment, addressing the immediate emotional impact.
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The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?
- A. Alert other staff to the client’s apparent escalation.
- B. Ask why the client is overreacting to the situation.
- C. Leave the room until the client has regained control.
- D. Apologize to the client for being late with the treatment.
Correct Answer: D
Rationale: Apologizing (D) validates the client’s distress and acknowledges the nurse’s role de-escalating the situation. Alerting staff (A) is secondary asking why (B) may escalate defensiveness and leaving (C) avoids communication.
The experienced nurse determines that the new nurse’s actions are therapeutic when managing the cognitively impaired client whose agitated behavior is escalating. Which nursing actions should have occurred? Select all that apply.
- A. Saying “Mr. Smith will you look at me please?”
- B. Saying “You seem upset. How can I help you?”
- C. Presenting the client with detailed expectations.
- D. Turning off the television in the room to decrease noise.
- E. Saying “Getting so angry will not help you get what you want.”
- F. Saying “Speaking as loud as the client to ensure that the client hears what is being said.”
Correct Answer: A ,B, D
Rationale: Using the client’s name (A) acknowledging upset (B) and reducing stimuli (D) calm agitation. Detailed expectations (C) challenging anger (E) or loud speech (F) may escalate.
The nurse is conducting an admission history on the client being hospitalized with symptoms characteristic of schizophrenia. Which interview question demonstrates that the nurse can identify the most prevalent comorbid substance abuse issue for the client with schizophrenia?
- A. “When did you last smoke or use marijuana?”
- B. “Did you bring any street drugs to the hospital?”
- C. “How much alcohol do you drink in a 24-hour period?”
- D. “Did you give the nursing assistant all your cigarettes and lighters?”
Correct Answer: D
Rationale: Nicotine use (D) is most prevalent (70-90%) in schizophrenia. Marijuana (A) street drugs (B) and alcohol (C) are less common.
The nurse is caring for the toddler who has been hospitalized for observation because of apnea spells that have led to cardiac arrest at home three times in the past 6 months. The nurse suspects Munchausen Syndrome by Proxy (MSP) and contacts the HCP who does not believe that this is a correct assessment of the condition of the child or of the family dynamics. What should the nurse do?
- A. Contact the head of the department of pediatrics to report the incident.
- B. Consult with the clinical charge nurse as to what action should be taken.
- C. Call a case conference involving physicians nurses and social workers.
- D. File a variance report indicating the HCP was notified but took no action.
Correct Answer: B
Rationale: Consulting the charge nurse (B) follows the chain of command for suspected MSP a hard-to-confirm abuse. Bypassing to the department head (A) calling a conference (C) or filing a variance (D) skips protocol.
The nurse is discharging the client from an inpatient treatment program for cocaine abuse. Which statement by the client indicates an accurate understanding about the disease process of addiction?
- A. “I’m really going to try to stay off cocaine. I’m not worried about alcohol since I’ve never had any problem with a glass or two of wine with dinner.”
- B. “Once my cravings go away I won’t need to go to Narcotics Anonymous (NA) anymore. I’ll be recovered and will be able to stay away from using cocaine.”
- C. “I feel much better after talking to my therapist. I didn’t realize that I was hurting so much emotionally. I must have been using to deal with my emotional problems.”
- D. “I didn’t realize that staying off drugs meant changing my thoughts and emotions. I thought I could just learn to stop using cocaine. NA will help me make these changes.”
Correct Answer: D
Rationale: Lifestyle change via NA (D) is key to recovery. Other substances (A) risk dependency recovery is lifelong (B) and addiction is primary not emotional (C).