Nokea
Which therapeutic activity is most helpful in facilitating reminiscence therapy among older adult clients?
- A. Discussing a current event topic
- B. Singing popular songs from the 1960s
- C. Reading an article from the newspaper
- D. Making decorations for a future holiday
Correct Answer: B
Rationale: Singing familiar songs from the past stimulates memories, enhancing engagement in reminiscence therapy.
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The client is being admitted to the ICU with drug overdose that resulted in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and is kicking shoving throwing items in the room and threatening staff. The charge nurse calls a behavioral situation code and 4-point restraints are applied by the team. Which intervention is most important for the nurse to implement next?
- A. Have staff members who were harmed complete an incident report.
- B. Contact the health care provider to obtain an order for restraint use.
- C. Document the client’s behavior and action taken in the nurse’s notes.
- D. Check that the client’s wrist restraints are tightly secured to the HOB.
Correct Answer: B
Rationale: A physician or licensed independent practitioner must prescribe restraints and assess the client within 1 hour of restraint placement for client and staff safety. Incident reports (A) follow treatment documentation (C) follows HCP contact and securing restraints to the HOB (D) risks circulation impairment.
Which nursing action is most appropriate for determining whether domestic abuse is occurring?
- A. Ask directly if domestic abuse is occurring.
- B. Arrange a second visit to validate suspicions.
- C. Assess the young children for signs of injury.
- D. Make inquiries among relatives or neighbors.
Correct Answer: A
Rationale: Directly asking about abuse in a safe, private setting encourages honest disclosure and is the most effective initial step to confirm suspicions.
Which of the following verbal communication methods is best to use with a client with dementia?
- A. Speak loudly to get the client's attention.
- B. Use short sentences when speaking to the client.
- C. Use written forms of communication.
- D. Allow the client to listen to news programs.
Correct Answer: B
Rationale: Short sentences are easier for dementia clients to process, enhancing comprehension and reducing frustration.
The nurse explains to the client's family the alcoholic's recovery process. What is the first step in recovering from alcohol?
- A. Admitting an inability to control drinking
- B. Forming a close support network
- C. Relying on some form of religious belief
- D. Checking into an inpatient rehabilitation unit
Correct Answer: A
Rationale: Admitting powerlessness over alcohol is the foundational step in recovery models like Alcoholics Anonymous, as it acknowledges the problem and initiates the commitment to change.
Which is the most desired outcome of a self-help group of rape victims?
- A. Obtaining mutual assistance with similar problems
- B. Receiving authoritative information about rape trauma
- C. Establishing new friendships with other victims
- D. Developing additional social skills for the future
Correct Answer: A
Rationale: Self-help groups provide mutual support, allowing victims to share experiences and coping strategies, fostering recovery through shared understanding.