Extract:

Question 1 of 5

A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, 'Maybe I shouldn't bother going. I wonder if I should just take more medication instead.' Which therapeutic response should the nurse make to the client?

Correct Answer: A

Rationale: Anxiety and fear are often present before stress testing. The nurse should explore a client's feelings if concerns are expressed. Option 1 is open-ended and is the only choice that is phrased to engender trust and the sharing of concerns by the client. Eliminate options that are inappropriate statements and limit communication.

Question 2 of 5

The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?

A. The client no longer experiences phobias and anxiety. B. The client no longer counts objects out loud. C. The client is no longer mute and withdrawn. D. The client no longer displays overreaction to events.

Correct Answer: C

Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.

Question 3 of 5

The nurse discovers a hospice client has expired. The family members are assembled in the facility's waiting room. Which of the following statements by the nurse would be the most appropriate?

A. My condolences on the passing of your family member. You may visit him if you wish. B. I will give you some time to spend with your loved one. Let me know if you need anything. C. You should view your loved one as a way of saying farewell. D. It would be best if you not view your loved one just yet.

Correct Answer: B

Rationale: This statement offers support, gives the family autonomy, and invites further communication, which is sensitive and appropriate.

Question 4 of 5

The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?

A. The client's blood pressure is 180/96 mm Hg. B. The client has right-sided weakness. C. The client has tinnitus. D. The client invents elaborate, improbable events.

Correct Answer: D

Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.

Question 5 of 5

While providing care to a 12-year-old client, the nurse observes small round burn scars on the client's arms and legs, bruising on the buttocks, and tenderness of the right jaw. The client is anxious, has poor eye contact, and denies being injured at home when the nurse asks questions. Based on these observations, the nurse suspects victimization. Which is the next priority question the nurse should therapeutically ask the client in providing a safe environment for the client?

A. Are you sure your parents didn't do this? B. You need to tell me now, or I'll call security, who did this to you? C. Is someone bullying you at school, or at home, or in your neighborhood? D. I can see this is difficult for you to talk about, you are safe here, but I need to ask you, who hurt you like this?

Correct Answer: D

Rationale: Based on the nurse's assessment data, the suspect of victimization needs to be analyzed to determine how the client received the old and new injuries. Option 4 offers the therapeutic approach for obtaining information using an open-ended question. It is important to determine if the injuries resulted from a family member or someone else outside the home. There are many forms of abuse besides physical abuse to consider such as sexual, emotional, and psychological abuse. Identifying the victimizer is important to stop the abuse and avoid further injuries. Safety is a priority concern for the client while in the care of the nurse and then after discharge from care. Option 1 implies that the nurse is challenging if the client is telling the truth. Option 2 could be perceived as demanding and a threat to the client to answer the question. Option 3 focuses on outside the family but there is not enough information given in the question to determine whether a family member is not suspected.