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Which nursing actions will best protect the client's safety? Select all that apply.
- A. Station a security guard outside the client's room at all times.
- B. Remove all cords, wires, and strings in the room.
- C. Provide paper dishes and plastic utensils.
- D. Assess whether the client has swallowed all medications.
- E. Ask a family member to stay with the client during the night.
- F. Check in on the client every 30 minutes.
Correct Answer: B,C,D,F
Rationale: Removing potential hazards, using safe utensils, ensuring medication compliance, and frequent checks minimize suicide risk by reducing means and monitoring behavior.
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The client who sustained a brain injury from an MVA is now experiencing aggression impulsivity and poor judgment. In teaching the family which area of the brain illustrated should the nurse identify as being affected?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: B
Rationale: The prefrontal cortex (Line B) modulates judgment aggression and impulsivity. Cortex (A) controls motor functions hypothalamus (C) regulates temperature/fluids and cerebellum (D) manages balance. image4.png
Which emotional responses are the parents most likely to experience immediately after the sudden death of their infant?
- A. Anger
- B. Guilt
- C. Fear
- D. Depression
Correct Answer: B
Rationale: Guilt is a common immediate response as parents often question their actions or feel responsible for the infant's death, reflecting early grief processing.
What is the most appropriate nursing action when the terminally ill client's death is imminent?
- A. Stay with the client and contact the family.
- B. Notify the hospital chaplain of the potential for death.
- C. Call the funeral home, alerting them of an imminent death.
- D. Transfer the client to the intensive care unit.
Correct Answer: A
Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.
Which findings strongly suggest that the client is experiencing an exacerbation of the bipolar disorder? Select all that apply.
- A. The client has been spending money extravagantly.
- B. The client has been avoiding social activities.
- C. The client has been methodically cleaning the house.
- D. The client has been staying up late to read.
- E. The client demonstrates increased sexual promiscuity.
- F. The client has increased anxiety when going outside the house.
Correct Answer: A,E
Rationale: Extravagant spending and sexual promiscuity are indicative of mania, a key feature of bipolar disorder exacerbation.
The client has been placed in restraints for violent behavior. Which statement best indicates the nurse’s understanding of the risk for client injury while being restrained?
- A. “Can you arrange to order the client’s favorite sandwich for his lunch?”
- B. “I need to make sure the restraints’ release mechanisms are working properly.”
- C. “I need someone to continuous monitor the client and relieve me for a few minutes.”
- D. “The client’s feet feel a little cool but they have a good pulse. I’ll get a pair of socks.”
Correct Answer: C
Rationale: Continuous monitoring (C) prevents injury during restraint. Nutrition (A) release mechanisms (B) and circulation checks (D) are secondary to constant observation.