Saunders Review
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is normal, expected event B. Experiencing early signs of ischemic bowel C. Not have NG tube removed D. Indicates inadequate pre-op bowel prep
A As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
A pre-op client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would MOST CLOSELY monitor which item in the pre-op period? A. Vitals B. Fluid balance C. Anxiety level D. Creatinine level
A Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.
The nurse is providing care to a child admitted for acute otitis media. What is the nurse's PRIORITY concern for this child? A. Acute pain B. Problems with skin integrity C. Risk for interrupted breathing patterns D. Mucous membrane dryness and crackin
A In acute otitis media, symptoms and signs such as acute ear pain, fever, and a bulging yellow or red tympanic membrane usually are present. Nursing interventions focus on relieving pain. Analgesic medications such as acetaminophen or ibuprofen are used to treat mild pain. The priority concern for this condition would be acute pain. Skin integrity, interrupted breathing patterns, and mucous membrane dryness and cracking are not priority concerns with this condition.
A client involved in a MVA presents to the ED with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will MOST LIKELY be prescribed? A. 5% dextrose in lactated Ringer's B. 0.33% sodium chloride (1/3 NS) C. 0.225% sodium chloride (1/4 NS) D. 0.45% sodium chloride (1/2 NS)
A The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated Ringer's solution (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, would move into the cells via osmosis.
The nurse is planning relapse prevention info for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which PRIMARY intervention? A. Including the client's support system in the teaching B. Facilitating weekly maintenance therapy C. Having the client restate discharge goals and strategies D. Stressing the importance of client compliance with the medication plan
A Of the options provided, including the client's support system in the teaching has the greatest effect on relapse prevention management because it will provide the client with valuable support. Although the remaining options are helpful, they all focus on the client's having the resources and abilities to be self-managing and self-reflective.
Which caste care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all A. Keep the cast clean and dry B. Allow the cast 48-72 hours to dry C. Keep the cast and extremity elevated D. Expect tingling and numbness in the extremity E. Use a hair dryer set on warm-hot setting to dry the cast F. Use a soft, padded object that will fit under the cast to scratch the skin under the cast
A, B, C A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The health care provider is notified immediately if circulatory impairment occurs.
An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all. A. Anosmia B. Chronic cough C. Purulent nasal discharge D. Intolerance to hot weather E. Intolerance to strong aromas
A, B, C Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and strong aromas are not characteristics.
A client is about to begin hemodialysis. Which measures should the nurse employ in the care of the client? Select all. A.Using sterile technique for needle insertion B. Using standard precautions in the care of the client C. Giving the client a mask to wear during connection to the machine D. Wearing full protective clothing: goggles, mask, gloves, and apron E. Covering the connection site with a bath blanket to enhance extremity warmth
A, B, C, D Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both nurse and client are extremely important. It also is imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and apron. The connection site should not be covered; it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.
The nurse is monitoring the IV infection of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all. A. Stop the infusion B. Notify healthcare provider C. Prepare to apply ice/heat to site D. Restart IV at distal part of the same vein E. Prepare to administer a prescribed antidote into the site F. Increase flow rate of the solution to flush the skin and subcutaneous tissue
A, B, C, E Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the IV administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.
A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all. A. Suction the client PRN B. Encourage coughing every 2 hr C. Low fowler's position D. Support neck incision when coughing E. Monitor respiratory status frequently
A, B, D, E The client's respiratory status is promoted by the use of high Fowler's position after this surgery. Low Fowler's position is avoided because it could result in increased venous pressure on the surgical site and increased risk of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2 hours, to support the neck incision when coughing, to suction periodically as needed, and to monitor the respiratory status frequently as prescribed.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all. A. Communicate expected behaviors to the client B. Ensure the client knows that they're not in charge of the nursing unit C. Assist the client in identifying ways of setting limits on personal behaviors D. Follow through about the consequences of behavior in a nonpunitive manner E. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups F. Have the client state the consequences for behaving in ways that are viewed as unacceptable
A, C, D, F Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights.
The nurse is admitting a newborn infant to the nursery and notes that the health care provider (HCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all. A. Protect the defect from trauma B. Protect sac or viscera with dry gauze C. Maintain a thermoneutral environment D. Feed newborn Q4H, 2-3 oz. of D5W E. Assess for associated birth defects such as cleft palate
A, C, E Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane. It is important to protect the defect from trauma and dryness. Saline soaked dressings should be applied. Thermoregulation for a newborn is always a concern. This newborn should be NPO (nothing by mouth) and have nasogastric suction applied for gastric decompression. There is an increased risk for this newborn to also have a cleft lip and/or cleft palate.
The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which interventions should the nurse include in the plan of care? Select all. A. Monitor for changes in mentation B. Encourage intake of low-protein C. Encourage intake of low-sodium D. Encourage fluid intake of at least 3000 mL per day E. Monitor vitals, skin turgor, and I&O
A, D, E The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor and intake and output should be monitored for signs of fluid volume deficit.
A hospitalized client experiencing delusions reports to the nurse "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? A. I don't believe this is true B. The doctor is not talking to the mob C. Do you feel afraid that people are trying to hurt you? D. What makes you think that the doctor wants to get rid of you?
C When delusional, a client truly believes what he or she thinks to be real is real. The client's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusions is inappropriate.
After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? A. Stroke B. Pernicious anemia C. Bacterial meningitis D. Peripheral arterial disease
B Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.
The nurse is caring for a client with a diagnosis of gout. Which lab result would the nurse expect to note in the client? A. Calcium 9 mg/dL B. Uric acid 9 mg/dL C. Potassium 4.1 mEq/L D. Phosphorus 3.1 mg/dL
B In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL (0.48 mmol/L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L) and for a female, from 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L). Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.
The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents? A. Administer at mealtimes B. Administer through a straw C. Mix with cereal D. Add to formula
B In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.
The RN is observing a LPN who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN should intervene if the RN notes the LPN performing which action? A. Assisting the client to ambulate B. Elevating the knee gatch on the client's bed C. Performing ROM exercises to the client's legs D. Removing the antiembolism stockings during morning care
B After a vaginal hysterectomy, the client is at risk for deep vein thrombosis or thrombophlebitis. The nurse should implement measures that prevent this complication. Range-of-motion exercises, antiembolism stockings, and ambulation are important measures to prevent this complication. Antiembolism stockings are removed to provide hygiene care and are then replaced. If the RN notes that the LPN used the knee gatch on the bed, the RN should intervene. This action would inhibit venous return, increasing the risk for deep vein thrombosis or thrombophlebitis.
The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a NEED FOR FURTHER INSTRUCTION? A. I'll record the number of movement or kicks B. I need to lie flat on my back to perform the procedure C. If I count <10 kicks in 2 hours, I should count the kicks again over the next 2 hours D. I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks
B The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the health care provider (HCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the HCP.
The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been EFFECTIVE? A. Induced by exercise B. Occurs at the same time each day C. Occurs at lower levels of activity D. Less predictable and a precursor of MI
B Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, usually in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity than those that previously precipitated the angina. Unstable angina also occurs at rest, is less predictable, and is often a precursor of myocardial infarction.
The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all. A. Bradycardia B. Pulsus paradoxus C. Distant heart sounds D. Falling BP E. Distended neck veins
B, C, D, E Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling BP, accompanied by pulsus paradoxus (a drop in inspiratory BP by more than 10 mm Hg).
The nurse is assessing for changes in skin color of a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all. A. Sclera B. Tongue C. Nail beds D. Elbows and heels E. Mucous membranes
B, C, E Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, nail beds, and mucous membranes. The sclerae are most useful in evaluating jaundice. Elbows and heels are not appropriate areas to assess for skin color changes.
The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all. A. Provide monetary relief B. Provide crisis counseling C. Identify and train personnel D. Issue presidential declarations E. Deploy National Guard troops F. Handle inquiries from families
B, C, F In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families.
A client is brought into the ED with a snake bite to the arm. Which treatment interventions should the nurse anticipate? Select all. A. Apply ice to site B. Deliver supplemental oxygen C. Apply a tourniquet just above the site D. Maintain the extremity at the level of the heart E. Infuse crystalloid fluids through 2 large-bore IV lines F. Immobilize the affected extremity in a position of function with a splint
B, D, E, F Interventions include giving supplemental oxygen, keeping the arm at the level of the heart, infusing crystalloid fluids through 2 large-bore IV lines, and immobilizing the arm in a position of function with a splint. Applying a tourniquet and placing ice on the area are contraindicated because they enhance the effect of the venom. Keep the person warm and provide calm reassurance. Also, apply continuous cardiac and blood pressure monitoring equipment to quickly detect clinical deterioration. Because venom can cause severe pain at the bite site, opioids are indicated. Provide tetanus prophylaxis and wound care as part of the collaborative plan of care.
The nurse in the health care provider's office is performing a postoperative assessment of a client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should provide which information to the client about her complaint? A. They're signs of complication B. Probably will be permanent C. Dissipate over several months and usually resolve after 1 year D. Nothing to worry about because most women who have this type of surgery experience this
C Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in most women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve by 1 year after surgery. These sensations are not a sign of a complication and are not permanent. The nurse would not tell the client that a complaint is nothing to worry about because this is nontherapeutic and avoids the client's concern.
The clinic nurse prepares instructions for a chemo who developed stomatitis after the administration of a course of antineoplastic medications. The nurse should provide the client with which instruction? A. Avoid foods and fluids for the next 12-24 hours B. Swab the mouth with lemon and glycerin 4x daily C. Rinse the mouth with a diluted solution of baking soda or saline D. Brush the teeth with a stiff-bristled toothbrush, and use dental floss TID
C Stomatitis (ulceration in the mouth) can result from the administration of antineoplastic medications. The client should be instructed to examine the mouth daily and report any signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with a diluted solution of baking soda or saline. Food and fluid are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet that includes milkshakes and ice cream. Instruct the client to avoid spicy foods and foods with hard crusts or edges. Lemon and glycerin swabs may cause pain and further irritation. The client should avoid brushing the teeth, particularly with a stiff-bristled toothbrush, and flossing when stomatitis is severe.
The nurse is caring for a chemo client with a low platelet aggregation level. Which likely caused this decreased platelet production? A. Anemia B. Thrombocytopenia C. Bone marrow suppression D. Low H/H counts
C Suppression of bone marrow function is a result of many chemotherapy medications leading to inhibition of platelet production. Because of bone marrow suppression, chemotherapy clients are at risk of bruising and bleeding, and these risks are increased by medications that inhibit platelet function, such as most conventional nonsteroidal antiinflammatory drugs (NSAIDs). Aspirin is especially dangerous because it causes irreversible inhibition of platelet aggregation. The other options are incorrect.
The result of a BPP of a 28 year old client at 36 weeks gestation after the ultrasound components is 8. Based on the results, the nurse should take which action? A. Notify primary provider B. Prepare client for labor induction C. Place fetal heart monitor on the client in order to do a nonstress test D. Provide the client with info regarding warning s/s of pregnancy and discharge her to home
C The BPP includes 5 components, one of which is an NST. Each of these components allows the practitioners to assess if the central nervous system is fully functional and that the fetus is not hypoxemic. Four components are included in the ultrasound portion of the profile in addition to an NST: fetal breathing movements, fetal movements, fetal tone, and amniotic fluid index. Each of the 5 components is given a score of either 2 or 0. Zero indicates an abnormal result, and a 2 indicates a normal result. After the ultrasound components, the client's BPP is 8 out of 8 possible points. This indicates fetal well-being, but there is a need to complete the BPP by obtaining an NST. Notifying the HCP can be eliminated because the BPP result thus far is normal. Labor induction can be eliminated because the client's gestational age is not term and the BPP reveals no abnormalities or the need for induction. To complete a BPP, an NST must be done; therefore, it is inappropriate to send the client home at this point in her care, so eliminate option 4.
Which goal addresses the therapeutic management needs of a client experiencing hallucinations? A. Support the client through the hallucination in a caring, therapeutic manner B. Provide the client with insight as to why he/she is experiencing the hallucination C. Facilitate the client's awareness that the hallucination is not the reality of the world D. Help the client to ignore the hallucination through appropriate coping mechanisms
C The goal of nursing interventions for the therapeutic management of hallucinations is to first help the client increase awareness so that he or she can distinguish between the misperception and reality. Having insight into why the hallucinations occur and possessing strategies to manage them effectively are skills needed to attain the stated goal of awareness of reality. Ignoring a hallucination is inappropriate and can be harmful. All nursing interventions should be provided with care and in a therapeutic manner; this is not a client-oriented goal but a nursing responsibility.
The nurse is planning the client assignments for the day. Which clients can be safely assigned to an UAP? Select all. A. Client receiving heparin infusion B. Client receiving blood transfusion C. Client receiving continuous oxygen at 2 L/min D. Client recovering from Guillain-Barre syndrome E. Client who returned from hip repair surgery F. Client on isolation for MRSA
C, D, F UAPs cannot be assigned to a client requiring care that is more than basic. UAPs do not have the education to safely care for clients requiring more than basic care. Assigning a UAP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).
The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate? A. Encourage the client's expression of feelings B. Assess the client's understanding of the disease process C. Encourage family members to share their feelings about the disease process D. Encourage the client to recognize that the body changes need to be dealt with
D Encouraging the client to understand that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. The remaining options are appropriate because they address the client and family feelings regarding the disorder.
The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the result of which lab study while the client is taking this medication? A. CD4+ T cell count B. Lymphocyte count C. Serum albumin D. Serum creatinine
D Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.
The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a NEED FOR ADDITIONAL INFO? A. My medications will help my anxious feelings B. I'll go to support group and talk about what I am feeling C. I need to get enough sleep and eat well to help prevent feeling anxious D. When I have command hallucinations, I'll call a friend and ask him what I should do
D The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.
A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor? A. Continue to assess the client's behavior and document clearly in the chart B. Report to the provider that the client is adapting to the unit and is feeling safe C. Notify the health team of these observations and alert them to the suspicion that the client is contemplating suicide D. Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide
D The sudden change in the depressed client's mood and affect may indicate that the client has come to a decision about suicide. The only way to be sure is to ask the client directly. Eliminate options that present strategies that would be used with any client. Avoid options that make unfounded assumptions such as a meaning of the behavior. Notifying others of your concern may be necessary at some point but does nothing to address the problem directly.
During a therapy session, a client with a personality disorder says to the nurse" You look so nice today. I love how you do your hair and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? A. Your comment is really inappropriate B. Thank you, the perfume was a gift C. Neither my hair nor my perfume is the focus of today's session D. The focus of today's session is on your issues, so lets get started
D The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle or those that are a social response and could be misinterpreted by the client.
