Nokea
Which of the following is a risk factor for shaken baby syndrome?
- A. Low socioeconomic status
- B. Inadequate parental education
- C. Having multiple siblings
- D. Physical disability of the caregiver
Correct Answer: A
Rationale: The correct answer is A: Low socioeconomic status. Low socioeconomic status can lead to increased stress levels and lack of access to resources, increasing the likelihood of caregiver frustration and potential for shaken baby syndrome. Inadequate parental education (B) may contribute, but is not as directly linked. Having multiple siblings (C) and physical disability of the caregiver (D) are not direct risk factors for shaken baby syndrome.
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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
- A. A client attempts to climb out of bed and repeatedly states she must get home.
- B. A client refuses to get out of bed and has no motivation to attend to daily hygiene.
- C. A client wants to know the current time while there is a clock on the wall.
- D. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).
Correct Answer: A
Rationale: The correct answer is A. Delirium is characterized by sudden onset confusion and disorientation. In this case, the client attempting to climb out of bed and repeatedly stating she must get home indicates altered mental status and confusion, which are common in delirium. The other choices do not align with typical manifestations of delirium. Choice B suggests lack of motivation, choice C is a normal behavior to check the time, and choice D is a reasonable request based on personal preference rather than a sign of delirium.
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
- A. Warn the client that further disruptions will result in seclusion.
- B. Ask the client to recommend consequences for her disruptive behavior.
- C. Set limits on the client's behavior and be consistent in approach.
- D. Ignore the client's behavior,realizing it is consistent with her illness.
Correct Answer: C
Rationale: The correct answer is C: Set limits on the client's behavior and be consistent in approach. This is the best course of action because it maintains a therapeutic environment while ensuring the safety and well-being of all clients. By setting limits, the nurse establishes boundaries for acceptable behavior during the manic episode, helping to prevent harm and maintain order on the unit. Consistency in approach is crucial to provide the client with structure and predictability, which can help manage the manic symptoms and reduce potential disruptions.
Choice A is not the best option as it may escalate the situation and does not address the underlying issue. Choice B is not appropriate as it puts the responsibility on the client to determine consequences, which may not be effective in managing the behavior. Choice D is incorrect as ignoring the behavior can compromise the safety of other clients and is not a therapeutic approach to managing manic episodes.
A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states,I'm frightened. Do you hear that? The voices are telling me to do terrible things. Which of the following responses by the nurse is appropriate?
- A. What are the voices telling you to do?
- B. You need to tell the voices to leave you alone.
- C. You need to understand that there are no voices.
- D. Why do you think you are hearing the voices?
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. **Acknowledge the client's experience**: By asking "What are the voices telling you to do?" the nurse validates the client's experience and shows empathy.
2. **Encourages communication**: This response opens up a dialogue and allows the nurse to gather more information for assessment and understanding.
3. **Avoids dismissing or denying the experience**: Options B and C dismiss or deny the existence of the voices, which can make the client feel unheard or misunderstood.
4. **Promotes therapeutic communication**: Asking about the content of the voices helps the nurse assess the client's level of distress and potential risk.
5. **Supports building trust**: By demonstrating active listening and showing interest in the client's experience, the nurse can build a trusting therapeutic relationship.
Summary:
- Option A is correct as it acknowledges the client's experience and promotes communication.
- Options B and C dismiss or deny the client's experience.
- Option D focuses on the cause rather
A nurse in a substance abuse clinic is assessing a client who is prescribed disulfiram (Antabuse). The client states he stopped the medication after developing severe nausea and vomiting. Which of the following does the nurse realize is most likely the cause of the client's symptoms?
- A. The client took an overdose of the medication.
- B. The client demonstrated an allergic response to the medication.
- C. The client experienced a common side effect of the medication.
- D. The client consumed alcohol while taking the medication.
Correct Answer: D
Rationale: The correct answer is D: The client consumed alcohol while taking the medication. Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. The symptoms of severe nausea and vomiting the client experienced are consistent with the disulfiram-alcohol reaction. This reaction occurs when alcohol is consumed while on disulfiram, leading to a buildup of acetaldehyde, causing discomfort.
Choice A: The client taking an overdose of the medication would typically result in different symptoms, such as neurological effects or liver toxicity.
Choice B: An allergic response to disulfiram would likely manifest as skin rash, itching, or difficulty breathing, rather than nausea and vomiting.
Choice C: While nausea and vomiting are common side effects of disulfiram, they are typically milder and occur when alcohol is consumed, not as a standalone symptom.