Nokea
An extremely angry patient with bipolar illness who just learned his wife has filed for divorce.
Which of the following responses by the nurse is MOST appropriate?
- A. Allow the patient to use the phone.
- B. Confront the patient about his anger and inappropriate plan of action.
- C. Do not allow the patient to use the phone because he is an involuntary patient.
- D. Set limits on the patient's phone use because he has been unable to control his behavior.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-patient is able to use phone unless otherwise indicated by court order or physician's order (2) has not lost civil right to use phone (3) denies patient his civil rights (4) inappropriate
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The nurse is preparing to discharge a client with a new diagnosis of asthma.
- A. What is the most important teaching point for a client with a new asthma diagnosis?
- B. Use a spacer with the metered-dose inhaler.
- C. Take the bronchodilator before the corticosteroid.
- D. Avoid exercise to prevent asthma attacks.
- E. Monitor peak flow readings daily.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.
The nurse is performing hypertension screening at the local grocery store. It would be MOST important for the nurse to complete which of the following tasks?
- A. Use a blood pressure cuff that overlaps the arm at least four inches.
- B. Support the client's arm above the level of the heart.
- C. Take two readings at least five minutes apart.
- D. Take the blood pressure after the client has exercised for 10 minutes.
Correct Answer: C
Rationale: Two readings five minutes apart ensure accuracy in hypertension screening. Options A, B, and D are incorrect techniques.
The nurse is caring for an aging client. Which statement the client makes indicates that he is having difficulty with the developmental tasks of aging?
- A. I like to make toys for my grandchildren.'
- B. I used to be a farmer, but now I can't do all that hard work.'
- C. I wish I had changed careers when I really wanted to; now it's too late.'
- D. We don't have as much money now as we did before I retired.'
Correct Answer: C
Rationale: Regret over unfulfilled career changes reflects difficulty achieving ego integrity, the developmental task of accepting one's life. Other statements show adaptation or acceptance.