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Questions 227

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Extract:


Question 1 of 5

The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:

Correct Answer: D

Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.

Extract:

A patient with a diagnosis of bipolar disorder has been drinking copious amounts of water and voiding frequently. The patient is experiencing muscle cramps, twitching, and is reporting dizziness.


Question 2 of 5

The nurse checks lab work for

Correct Answer: B

Rationale: Symptoms suggest hyponatremia from excessive water intake, requiring electrolyte assessment.

Extract:


Question 3 of 5

The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions is MOST appropriate?

Correct Answer: B

Rationale: Listening to music with headphones can distract from auditory hallucinations, reducing their intensity. Arguing (
A) increases agitation, ignoring voices (
C) is ineffective, and administering medication (
D) is appropriate but not the most immediate non-pharmacologic intervention.

Question 4 of 5

The parent of a young adult recently diagnosed as being HIV positive calls the clinic in a panic saying, 'My son just cut himself shaving, and there is blood all over the bathroom. What should I do?' How should the nurse respond?

Correct Answer: C

Rationale: Household bleach effectively disinfects HIV in blood spills, and gloves protect the parent, following standard precautions.

Extract:

The nurse is aware that immunization of infants does not begin until 2 months of age because:


Question 5 of 5

The nurse is aware that immunization of infants does not begin until 2 months of age because:

Correct Answer: D

Rationale: Maternal antibodies present at birth interfere with vaccine-induced immunity until about 2 months.

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