The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn’t visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate? A. Approach the client and touch him to get his attention. B. Encourage the client… Read More »
Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg Correct Answer: A. Heart rate of 120… Read More »
Which of the following will the nurse use when communicating with a client who has a cognitive impairment? A. Complete explanations with multiple details B. Picture or gestures instead of words C. Stimulating words and phrases to capture the client’s attention D. Short words and simple sentences … Read More »
A client with paranoid-type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should A. Tell him that she’ll leave for now but will return soon. B. Ask him if it’s okay if she sits quietly with him. C. Ask him why he wants to be left alone.… Read More »
Nurse Amy is aware that the client is at highest risk for suicide? A. One who appears depressed frequently thinks of dying and gives away all personal possessions. B. One who plans a violent death and has the means readily available. C. One who tells others that he or she might do something if… Read More »
A 75-year-old client has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client: A. Denies confusion by being jovial B. Pretends to be someone else C. Rationalizes various behaviors D. Fills in memory gaps with fantasy Correct Answer: D. Fills in memory gaps… Read More »
Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s interpersonal communication with the client and specific nursing interventions must be: A. Clearly identified with boundaries and specifically defined roles. B. Warm and non-threatening. C. Centered on clearly defined limits and expression of empathy.… Read More »
Nurse Penny is aware that the following medical conditions are commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A Correct Answer: C. Diabetes mellitus Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. Girls and… Read More »
An elderly client with Alzheimer’s disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A. Tell the client family that it is time to get dressed. B. Obtain assistance to restrain the client for safety. C. Remain calm… Read More »
When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following? A. Results of treatment are rapid and dramatic but may not last. B. Although uncomfortable, this reaction isn’t serious. C. The client shouldn’t buy drugs on the street.… Read More »