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You are caring for a client who has been assessed as having a past history of violent and dangerous behaviors towards others. You, as the nurse, are concerned about this client's past history and the dangers that may adversely affect others including staff, visitors and other clients on the unit. What is the first thing that you should do to prevent violence towards others?
- A. Restrain the client
- B. Place the client in seclusion
- C. Get an order for a sedating medication
- D. Establish trust with the client.
Correct Answer: D
Rationale: Establishing trust is the first step in de-escalating potential violence, as it fosters a therapeutic relationship and reduces the client's anxiety or agitation, which could otherwise escalate into violent behavior.
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A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse:
- A. When desired because sterilization is immediate.
- B. As soon as scrotal edema and tenderness resolve.
- C. When the sperm count reflects sterilization.
- D. After 6 to 10 ejaculations.
Correct Answer: C
Rationale: A vasectomy requires confirmation of azoospermia (no sperm in semen) via sperm count before unprotected intercourse to ensure sterilization, as sperm may remain in the reproductive tract initially.
A client with schizophrenia is prescribed risperidone (Risperdal). The nurse should teach the client to report which side effect immediately?
- A. Weight gain
- B. Dry mouth
- C. Tremors
- D. Insomnia
Correct Answer: C
Rationale: Tremors may indicate extrapyramidal side effects, such as parkinsonism, which require prompt reporting to adjust the dose or add an antiparkinsonian medication.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
- A. Changes in vital signs
- B. Signs of vaginal bruising
- C. Client reporting a tearing sensation
- D. Client reporting intense vaginal pressure
Correct Answer: A
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the client received anesthesia, she would not feel pain or pressure.
The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client has a need for further teaching if the client makes which statement?
- A. An anesthetic throat spray will be used.
- B. A signed informed consent is necessary.
- C. Medication will be given orally for sedation.
- D. It is important to lie still during the procedure.
Correct Answer: C
Rationale: Intravenous sedation (not oral) is given to relax the client, and an anesthetic throat spray is used to help keep the client from gagging as the endoscope is passed. The client has to sign an informed consent form. The client also needs to lie still for ERCP, which takes about an hour to perform.