Answers
After returning to work after a weekend off the nurse gets report that a depressed client
has been in bed all weekend. What should the nurse to first? Answer- Assist the client
out of bed and involve in activity.
A client with dementia uses the defense mechanism of confabulation. What is the
reasoning? Answer- To decrease anxiety.
A husband states to the nurse that his wife is not sleeping, buying impulsively, taking
last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx?
Answer- Disturbed thought process.
A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive
and continually interrupts the group. What is the nurse's best response? Answer- When
you interrupt, I cannot explain what to do to the group.
When performing a MSE on a client which assessment intervention would best assist
the nurse? Answer- Ask the client to interpret the proverb a stitch in time saves nine.
A client comes in after being in a car accident and is experiencing alcohol withdrawal,
magnesium level of 1.1, cardiac dysthrythmias. What would you give first? Answer-
Magnesium.
A woman is just told of her husband's dx of terminal cancer. What would the nurse offer
for the spouse (wife)? Answer- How would you like to be involved with your husband's
care?
A nurse is to remove staples from an abdominal incision, the client is very anxious.
What is the most important intervention? Answer- Attempt to distract the client with
general conversation.
A man who was stranded on the roof of his house for two days after a natural disaster,
months later ... Answer- Implement anxiety control strategies.
A man dx with bipolar disorder states, "I don't understand, I believe in God and have not
done anything to deserve this". What is the nurse's best response? Answer- You didn't
do anything wrong. You have a chemical imbalance in your brain.