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Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?
- A. Tell me about the visit with your significant other. I can see that you are feeling lonely.
- B. I noticed that you were more insulting to the evening group after your significant other left. Why is that?
- C. Why don't you try to make some friends here so you won't feel so lonely?
- D. It sounds like your visit with your significant other was important to you. How did it go?
- E. None
- F. None
Correct Answer: D
Rationale: This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
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The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?
- A. Places food on the unaffected side of the mouth.
- B. Raises the head of the bed to 80 degrees.
- C. Positions the head with the chin tilted slightly downward.
- D. Allows 30 minutes of rest before feeding.
Correct Answer: B
Rationale: Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort.
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
- A. Blood pressure.
- B. Respiratory rate.
- C. Temperature.
- D. Pulse rate.
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation. Therefore, the nurse should obtain the respiratory rate first.
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.
After a week of bed rest, a client is being assisted to a chair for the first time.The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
- A. Determine how the client feels.
- B. Support the client when rising.
- C. Offer a pair of non-skid socks.
- D. Place the chair by the bed.
Correct Answer: A
Rationale: After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels. This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.