Nokea
Which of the following identified assessment criteria is the highest priority for this client?
- A. The number of characteristics of the client's bowel movements
- B. How much the client knows about colostomy care
- C. Which coping mechanisms the client uses for handling stress
- D. The types of relationships the client has with peers
Correct Answer: A
Rationale: Monitoring bowel movements is critical in ulcerative colitis to assess disease activity and guide treatment, prioritizing physical health.
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The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?
- A. Call the mental health unit to arrange for inpatient treatment.
- B. Give medications to reverse the effects of the hallucinogenic drug.
- C. Stay with the client to protect the client from self-harm until relieved.
- D. Call hospital security so security staff is present to protect staff from injury.
Correct Answer: C
Rationale: Staying with the client (C) prevents self-harm due to altered perception. Inpatient arrangements (A) reversal drugs (B unavailable) and security (D) are secondary.
Which nursing action is the highest priority during the immediate care of a rape victim?
- A. Documenting the circumstances of the rape
- B. Keeping contact with strangers to a minimum
- C. Offering the victim a choice of sedatives
- D. Providing a bath basin, gown, towel, and washcloth
Correct Answer: B
Rationale: Minimizing contact with strangers protects the victim's privacy and reduces distress, prioritizing emotional safety in the immediate aftermath.
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 client has been violent toward other clients on a mental health unit and interventions have failed. During the application of restraints which action by the team leader will gain the greatest cooperation from the client?
- A. Showing sympathy by apologizing for the need to restrain the client
- B. Dispassionately explaining why and how the restraints will be applied
- C. Affording the client one last opportunity to avoid restraints by “behaving”
- D. Offering to remove the restraints as soon as the client can “control the anger”
Correct Answer: B
Rationale: Explaining why and how restraints are applied (B) reduces resistance. Apologizing (A) implies mistreatment negotiating (C) undermines the decision and promising removal (D) is ineffective.
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.