Nokea
Which translation method is most beneficial for the client when the nurse obtains the client's history?
- A. A translation card that includes key words, phrases, and pictures
- B. A translator who speaks the client's language
- C. A hospital housekeeper who speaks the client's language
- D. The client's family member who can translate the process
Correct Answer: B
Rationale: A professional translator ensures accurate and confidential communication, critical for obtaining a reliable health history.
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The 19-year old client regularly abuses dextromethorphan (DXM). Which activity if performed under the influence of dextromethorphan places the client at highest risk for complications related to DXM abuse?
- A. Dancing at a nightclub
- B. Competing in a swim meet
- C. Snow-skiing on spring break
- D. Fishing from a shaded shoreline
Correct Answer: A
Rationale: Dancing (A) risks hyperthermia with DXM. Swimming (B) skiing (C) and fishing (D) are cooler lower-risk activities.
Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.
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.
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.
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.