Nokea
Which nursing intervention is most beneficial for the client's spouse at this time?
- A. Suggesting that the spouse make an appointment for a physical examination
- B. Discussing modifying the amount of time the spouse devotes to care-giving
- C. Reminding the spouse of the scheduled times for visiting clients on the unit
- D. Explaining that many staff are available to care for the client
Correct Answer: B
Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.
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The nurse reviews various treatment options with the group members. Which of the following are considered most therapeutic in treating obsessive-compulsive disorder (OCD)? Select all that apply.
- A. Selective serotonin reuptake inhibitors (SSRIs) such as fluvoxamine (Luvox)
- B. Electroconvulsive therapy (ECT)
- C. Cognitive-behavioral therapy
- D. Surgical prefrontal lobotomy
- E. Tranquilizers such as diazepam (Valium)
- F. A self-help class on the Internet
Correct Answer: A,C
Rationale: SSRIs and cognitive-behavioral therapy, particularly exposure and response prevention, are evidence-based treatments for OCD, targeting symptoms effectively.
What suggestion can the nurse make if the client complains of feeling dizzy when taking doxepin (Sinequan) at bedtime as prescribed?
- A. Place a cool compress on your forehead.
- B. Get up slowly from a seated position.
- C. Remain in bed with your feet elevated above your heart.
- D. Take some deep breaths before getting out of bed.
Correct Answer: B
Rationale: Rising slowly minimizes orthostatic hypotension, a common side effect of doxepin, reducing dizziness.
The NA is helping the ED nurse admit a woman who is the victim of spousal abuse and marital rape. The NA asks the nurse what should be done with the woman’s torn and soiled clothing. What is the nurse’s best response?
- A. “Place items in a plastic bag and avoid blood and body fluid contact.”
- B. “Ask the woman what she wants done with her clothing; she may want them discarded.”
- C. “These may be needed by the police. I will remove them and place in separate paper bags.”
- D. “Fold each article of clothing and leave them with her; she can decide later about disposal.”
Correct Answer: C
Rationale: Placing clothing in paper bags (C) preserves evidence for police. Plastic bags (A) cause mold asking the victim (B) or leaving with her (D) risks evidence loss.
While caring for a client who is withdrawing from alcohol, the nurse must assess for what additional complication?
- A. Hypothermia
- B. Seizures
- C. Ascites
- D. Jaundice
Correct Answer: B
Rationale: Seizures are a serious complication of alcohol withdrawal, requiring vigilant monitoring due to their potential for harm.
If the client's pain is the result of a panic attack, which findings will the nurse most likely note during the physical assessment? Select all that apply.
- A. Tachycardia
- B. Hypotension
- C. Increased salivation
- D. Constricted pupils
- E. Sweating
- F. Unsteady gait
Correct Answer: A,E
Rationale: Panic attacks typically cause tachycardia and sweating due to sympathetic nervous system activation, reflecting acute anxiety.