Nokea
Which nursing assessment is critical to ensuring the client's well-being during the home visit?
- A. The caregiver's understanding of the symptoms the client manifests
- B. The caregiver's understanding of when the client must return
- C. The caregiver's understanding of when to administer medications
- D. The caregiver's understanding of how to provide hygiene measures
Correct Answer: C
Rationale: Proper medication administration is critical for Alzheimer's clients, ensuring symptom management and safety during the visit.
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When the nurse reviews information about lithium carbonate (Lithane) with the client, which instructions are most important to stress? Select all that apply.
- A. Take a high-potency vitamin each morning.
- B. Refrain from sexual activity while taking this medication.
- C. Notify the physician if urine output increases.
- D. Maintain an adequate intake of sodium and fluids.
- E. Have periodic blood tests to monitor serum levels of the drug.
Correct Answer: C,D,E
Rationale: Monitoring urine output, maintaining sodium/fluid balance, and regular blood tests are critical to prevent lithium toxicity and ensure safe therapy.
Staff are debriefing following the client’s violent episode. Which information should be included in the debriefing session? Select all that apply.
- A. Client’s coping mechanisms post-event
- B. The client’s history of violent behavior
- C. Adherence to instructional policies and procedures
- D. Staff’s feelings regarding the effectiveness of the team
- E. Staff’s ability to respond to the client therapeutically post-event
Correct Answer: C ,D, E
Rationale: Debriefing includes policy adherence (C) team effectiveness (D) and therapeutic response (E) to identify training needs. Client coping (A) and history (B) are not debriefing focuses.
The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?
- A. The client’s own private room down the hall
- B. The unit’s common television dayroom
- C. An outdoor sheltered client smoking area
- D. An out-of-the-way corner near the nursing station
Correct Answer: D
Rationale: A quiet visible corner near the station (D) aids de-escalation. Private rooms (A) and outdoor areas (C) lack visibility and the dayroom (B) is too stimulating.
The 19-year old client regularly abuses dextromethorphan (DXM). Which activity if performed under the influence of dextromethorphan places the client at highest risk for complications related to DXM abuse?
- A. Dancing at a nightclub
- B. Competing in a swim meet
- C. Snow-skiing on spring break
- D. Fishing from a shaded shoreline
Correct Answer: A
Rationale: Dancing (A) risks hyperthermia with DXM. Swimming (B) skiing (C) and fishing (D) are cooler lower-risk activities.
Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.