Nokea
Which statement made by the client diagnosed with human immunodeficiency virus (HIV) would the nurse interpret as the most serious indication of an increased risk for suicide?
- A. I have been having recurring dreams about dying.
- B. How many people have died from HIV?
- C. Will I be alert when I'm near death?
- D. Everyone would be better off without me.
Correct Answer: D
Rationale: Expressing that others would be better off without them suggests feelings of worthlessness and hopelessness, strong indicators of suicidal ideation.
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The client is started on buprenorphine with naloxone (Suboxone) sublingual for opiate addiction. Which statements indicate that the client understood the nurse’s instructions about the medication? Select all that apply.
- A. “The medication can slow or stop my breathing. I should only take what is prescribed.”
- B. “I’m taking this non habit-forming medication to help stop my craving for opiate drugs.”
- C. “If I suddenly stop taking buprenorphine and naloxone I could experience withdrawal.”
- D. “I can take the tablet whole or crush it and take it with food to make it more palatable.”
- E. “This drug is highly abused; I should not share this or keep it where it can be stolen.”
Correct Answer: A ,C, E
Rationale: Suboxone risks respiratory depression (A) causes withdrawal if stopped (C) and is abusable (E). It’s habit-forming (B) and sublingual tablets shouldn’t be crushed (D).
Which action is most appropriate if the nurse discovers the oriented older couple having consensual sexual intercourse?
- A. Report it to their adult children.
- B. Restore a measure of privacy.
- C. Suggest they become roommates.
- D. Censure their sexual activity.
Correct Answer: B
Rationale: Restoring privacy respects the couple's autonomy and dignity, supporting their right to consensual intimacy.
If the angry client is out of control and refuses a p.r.n. sedative medication, the nurse has which legal option?
- A. The nurse must respect the client's right to refuse the ordered medication.
- B. The nurse must administer the medication to protect the safety of self and others.
- C. The nurse must get permission from a probate court judge to administer the medication.
- D. The nurse should ask the hospital's attorney about the client's right to refuse treatment.
Correct Answer: A
Rationale: Clients have the right to refuse medication unless they pose an imminent danger, in which case emergency protocols may apply, but respect for autonomy is primary.
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.
The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?
- A. The client’s own private room down the hall
- B. The unit’s common television dayroom
- C. An outdoor sheltered client smoking area
- D. An out-of-the-way corner near the nursing station
Correct Answer: D
Rationale: A quiet visible corner near the station (D) aids de-escalation. Private rooms (A) and outdoor areas (C) lack visibility and the dayroom (B) is too stimulating.