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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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Which technique is most therapeutic for helping clients with dementia remain oriented?
- A. Address all clients using their first name.
- B. Ask clients to identify their goals for the day.
- C. Assign clients to greet visitors each day.
- D. Post large calendars with the current date.
Correct Answer: D
Rationale: Large calendars provide a constant visual cue, aiding orientation to time in clients with dementia.
If the physician prescribes imipramine hydrochloride (Tofranil) for the client, the nurse should assess for which therapeutic drug effect first?
- A. Absence of suicidal ideation
- B. Improved concentration
- C. Decreased agitation
- D. Regulated mood
Correct Answer: D
Rationale: Regulated mood is the primary therapeutic effect of imipramine, addressing the core symptoms of depression.
The client uses methamphetamine regularly. Which subjective quote documented by the nurse demonstrates the client using pathological projection as a coping mechanism?
- A. “I’m here to get help. Everything will be all right again if I can just stop using drugs.”
- B. “My dad and I don’t get along. He thinks that I’m a failure and can’t do anything right.”
- C. “I’m not giving up alcohol just the methamphetamine. I never had a problem with alcohol.”
- D. “I can’t go back to work. I’d be so embarrassed if anyone found out I’ve been in treatment.”
Correct Answer: B
Rationale: Blaming dad for failure (B) is projection. Simplifying issues (A) is ignoring dismissing alcohol (C) is denial embarrassment (D) is perfectionism.
The student participating in college sports is suspected of abusing anabolic steroids and is referred to the college’s health service. Which nursing assessment findings are consistent with anabolic steroid abuse? Select all that apply.
- A. Acne vulgaris
- B. Aggressive behavior
- C. Heavy menstruation
- D. Urinary tract infection
- E. Thickening of the hair
- F. Edema of the hands and feet
Correct Answer: A ,B ,D, E
Rationale: Anabolic steroids cause acne (A) aggression (B) UTIs (D) and hair thinning (E not thickening). Heavy menstruation (C) is incorrect; menses cease. Edema (F) may occur but isn’t selected.
The emergency department nurse describes procedures and their purposes to the rape victim before they are implemented. What is the rationale for the nurse's action?
- A. It diminishes feelings of powerlessness.
- B. It tends to reduce the client's anxiety.
- C. It is a policy of the emergency department.
- D. It meets the client's need for teaching.
Correct Answer: A
Rationale: Explaining procedures empowers the victim by restoring some control, counteracting the powerlessness experienced during the assault.