WITH COMPLETE ANSWERS 2024
A nurse is performing a cognitive assessment to distinguish delirium from
dementia in a client whose family reports episodes of confusion. Which of the
following assessment findings supports the nurse's suspicion of delirium?
Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
A nurse is caring for a client who gave birth to a stillborn baby. Which of the
following statements should the nurse make?
"I'll stay with you just in case you want to talk."
This response demonstrates the therapeutic communication techniques of offering self
and indicates the nurse's interest in the client and a desire to understand the client's
feelings.
A nurse is caring for four clients in an emergency department. The nurse should
identify that which of the following clients can give informed consent?
A 35-year-old client who has major depressive disorder.
A client who has major depressive disorder is capable of making health care decisions
unless the client is determined to be legally incompetent.
A nurse is teaching a newly licensed nurse about nursing care plans for clients
who have depressive disorders. Which of the following statements by the newly
licensed nurse indicates an understanding of the teaching?
"I will update the plan of care as a client's manifestations of depression change."
The nurse should update the plan of care as a client's status and needs change.
A nurse on a medical-surgical unit is assessing a client who sustained injuries 12
hr ago following a motor-vehicle crash. The client's admission blood alcohol level
, was 325 mg/dL. Which of the following findings should indicate to the nurse that
the client is experiencing alcohol withdrawal?
Blood pressure 154/96 mm Hg
Physical manifestations of alcohol withdrawal occur in addition to psychological effects.
A client who is experiencing alcohol withdrawal is expected to have hypertension,
tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to
rule out infection in the client who has a fever.
A nurse is planning care for a client who has made repeated physical threats
toward others on the unit. Although the client does not want to leave the unit, the
nurse requests the provider to transfer the client to a unit that is equipped to
manage violent behavior. Which of the following ethical principles should the
nurse apply in this situation?
Nonmaleficence
It is the responsibility of the nurse to do no harm to clients. The nurse is applying the
ethical principle of nonmaleficence by requesting to transfer this client to a unit better
able to manage their behavior and thereby prevent injury to others on the unit.
A nurse is discussing a 12-step program with a client who has alcohol use
disorder and is in an acute care facility undergoing detoxification. Which of the
following information should the nurse include in the teaching?
The client should obtain a sponsor before discharge for an increased chance of
recovery.
The nurse should teach the client that peer support has been shown to increase
program attendance and the chances of recovery. If the client does not have a sponsor,
they can be assigned one when they begin attending the program.
A nurse is creating a plan of care for a client who has been placed in seclusion
after threatening to harm others on the unit. Which of the following interventions
should the nurse include in the plan?