Nokea
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
- A. Conveying empathy and encouraging ventilation.
- B. Using calm, firm directions to get the client to a quiet room.
- C. Putting the client in restraints.
- D. Discussing alternative strategies for when the client is angry in the future.
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
You may also like to solve these questions
The nurse is teaching a client with a new ileostomy about dietary modifications. Which food should be avoided?
- A. Rice.
- B. Corn.
- C. Bananas.
- D. Yogurt.
Correct Answer: B
Rationale: Corn is high in fiber and hard to digest, which can cause blockages in a new ileostomy.
The nurse is transferring a client who is G4 P3 at 25 weeks' gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this preeclamptic client, what should be included in the transfer report about this client? Select all that apply.
- A. Record of blood pressure trends
- B. Record of urine protein
- C. Edema observed by health care provider
- D. Client use of dietary sodium
- E. Fetal position
- F. Fetal heart rate pattern
Correct Answer: A,B,C,E,F,G
Rationale: For a client with preeclampsia, the transfer report should include blood pressure trends, urine protein levels, edema observations, fetal position, fetal heart rate patterns, and medical/nursing interventions, as these are critical for monitoring maternal and fetal status. Dietary sodium use is less critical unless specifically restricted.
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
- A. Idea of reference.
- B. Thought insertion.
- C. Visual hallucination.
- D. Neologism.
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Monitoring the client for at least 15-30 minutes after starting a transfusion is critical to detect acute reactions like hemolysis or allergic responses.
An older client has been prescribed casanthranol on a long-term basis to treat constipation. The nurse determines that which laboratory finding is a result of the side/adverse effects of this medication?
- A. Sodium 135 mEq/L (135 mmol/L)
- B. Sodium 145 mEq/L (145 mmol/L)
- C. Potassium 3.1 mEq/L (3.1 mmol/L)
- D. Potassium 5.0 mEq/L (5.0 mmol/L)
Correct Answer: C
Rationale: Hypokalemia can result from long-term use of casanthranol, which is a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal range for sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The remaining options all suggest normal values.