Nokea
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Which of the following responses, if made by the nurse, is BEST?
- A. You can trust me. There are no agents here.'
- B. You must feel afraid if you believe that, but there are no agents here.'
- C. No one here will hurt you. They are here to help you.'
- D. Agents? Tell me more about what you mean.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them
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The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority?
- A. Alteration in oxygen perfusion
- B. Alteration in comfort/pain
- C. Alteration in mobility
- D. Alteration in sensory perception
Correct Answer: A
Rationale: Acute Respiratory Distress Syndrome causes severe hypoxemia, making alteration in oxygen perfusion the priority nursing diagnosis to ensure adequate oxygenation. Pain , mobility , and sensory perception are secondary in this life-threatening condition.
A low-income client needing to satisfy essential protein needs.
Which of the following foods would the nurse encourage a low-income client to eat to satisfy essential protein needs?
- A. Legumes.
- B. Red meat.
- C. Seafood.
- D. Cheese.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase
The nurse is caring for a client with a history of osteoporosis.
- A. Which intervention is most effective for preventing fractures in a client with osteoporosis?
- B. Encourage weight-bearing exercises.
- C. Administer vitamin C supplements.
- D. Restrict calcium intake.
- E. Encourage bed rest to prevent falls.
Correct Answer: A
Rationale: Weight-bearing exercises strengthen bones, reducing fracture risk in osteoporosis. Vitamin C is less critical than calcium and vitamin D, calcium restriction worsens bone loss, and bed rest increases bone resorption.
A 69-year-old woman has been receiving total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse would expect the patient to exhibit
- A. tinnitus, vertigo, blurred vision.
- B. fever, malaise, anorexia.
- C. diaphoresis, confusion, tachycardia.
- D. hyperpnea, flushed face, diarrhea.
Correct Answer: C
Rationale: insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
The nurse is teaching a client with a new diagnosis of gout about colchicine. Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any diarrhea.
- C. Stop the medication if gout attacks cease.
- D. Avoid regular joint exams.
Correct Answer: B
Rationale: Diarrhea is a serious colchicine side effect, indicating potential toxicity. Options A, C, and D are incorrect.