Extract:

Question 1 of 5

A primigravida client who came to the clinic has been diagnosed with a urinary tract infection. She repeatedly verbalizes concern regarding the safety of the fetus. Which should the nurse address first?

Correct Answer: A

Rationale: The primary concern of this client is the safety of her fetus rather than herself. The priority for the nurse to address at this time is the issues regarding safety. The remaining options lack this priority.

Question 2 of 5

A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?

A. Guided imagery and limiting fluids B. Relaxation and breathing techniques C. Biofeedback and coughing techniques D. Distraction and increased dietary carbohydrates

Correct Answer: B

Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.

Question 3 of 5

The nurse talks with a child who has been sexually abused by a family member. The child asks the nurse, 'If I tell you something, will you tell anyone my secret?' Which response by the nurse to the client is appropriate?

A. I will not tell anyone your secret. B. I will not tell your mom and dad. C. I'll call the nursing supervisor as a witness. D. I cannot keep this information a secret.

Correct Answer: D

Rationale: Nurses are mandated reporters and cannot promise confidentiality in cases of abuse, as reporting to authorities is required to protect the child. This response is honest and maintains trust while adhering to legal and ethical obligations.

Question 4 of 5

The nurse is caring for an elderly female client who presents as being alert and oriented. In the late afternoon, the client becomes extremely agitated and confused. Which of the following responses by the nurse is most appropriate?

A. call a family member to come and stay with the client B. call the health care provider and ask for an order for Xanax C. reorient the client and offer distraction and reassurance in a soft voice D. tell the client that if she does not cooperate, she will be placed in restraints

Correct Answer: C

Rationale: This behavior suggests sundowning, common in elderly clients. Reorientation and reassurance are appropriate non-pharmacological interventions.

Question 5 of 5

The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.

A. administers medications as ordered B. uses gentle touch to reassure the client C. tells the client that others see or hear what he does D. distracts the client by placing him in the dayroom with others E. asks the client if he hears voices telling him to harm himself or others

Correct Answer: A,E

Rationale: Administering medications (
A) helps manage hallucinations, and asking about harmful voices (E) assesses safety.
Touch (
B) may be misinterpreted, validating hallucinations (
C) is harmful, and distraction in a dayroom (
D) may overwhelm the client.