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Which technique is most therapeutic for helping clients with dementia remain oriented?
- A. Address all clients using their first name.
- B. Ask clients to identify their goals for the day.
- C. Assign clients to greet visitors each day.
- D. Post large calendars with the current date.
Correct Answer: D
Rationale: Large calendars provide a constant visual cue, aiding orientation to time in clients with dementia.
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The nurse assesses the client every 15 minutes. What objective evidence will the nurse detect that indicates that the restraints are too tight? Select all that apply.
- A. The client reports being unable to move the right hand.
- B. The client's fingers and toes are pale.
- C. The client reports having pain.
- D. Capillary refill is greater than 6 seconds.
- E. There is excoriation around the wrist.
- F. The client reports numbness and tingling.
Correct Answer: B,D,F
Rationale: Pallor, prolonged capillary refill, and numbness indicate impaired circulation, suggesting restraints are too tight and compromising blood flow.
The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?
- A. Allow the parent to enter the room and see the child.
- B. Tell the parent that the HCP wants to speak with the parent first.
- C. Contact Social Services to report the parent’s abusive behavior.
- D. Initiate the emergency response system for behavioral situations.
Correct Answer: D
Rationale: Initiating the emergency response (D) ensures safety. Allowing entry (A) deferring to HCP (B) or reporting to Social Services (C likely already done) are inappropriate.
The emergency department nurse describes procedures and their purposes to the rape victim before they are implemented. What is the rationale for the nurse's action?
- A. It diminishes feelings of powerlessness.
- B. It tends to reduce the client's anxiety.
- C. It is a policy of the emergency department.
- D. It meets the client's need for teaching.
Correct Answer: A
Rationale: Explaining procedures empowers the victim by restoring some control, counteracting the powerlessness experienced during the assault.
Which approach is best for managing the client's care?
- A. Use a nonjudgmental manner when cleaning the client of stool.
- B. Ask the client's spouse to perform hygiene measures.
- C. Hold the client responsible for all hygiene.
- D. Assign same-gender nurses to care for the client.
Correct Answer: A
Rationale: A nonjudgmental approach preserves the client's dignity, reducing embarrassment and supporting self-esteem during hygiene care.
When the counselor asks the members of the post-traumatic stress disorder (PTSD) support group to draw pictures of their traumatic experiences, the nurse understands that the primary purpose for drawing is to achieve what outcome?
- A. Deal consciously with painful memories
- B. Bond with other group members
- C. Receive approval from group members
- D. Justify participation in the group
Correct Answer: A
Rationale: Drawing traumatic experiences externalizes memories, helping clients confront and process painful events in a controlled, therapeutic way.