NSG 2400 Exam 1 EAQ
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,The nurse notices that one of her clients, who has depression, is sitting by the window
crying. What is the most appropriate response by the nurse?
1
"It's okay. No need to cry or worry while you're here. We all feel down now and
then." 2
"Please don't consider suicide. It really isn't an appropriate way out of your
troubles." 3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if
you would like."
4
"Why don't you go into the dayroom and join the card game going on? That'll take your
mind off of your problems for a while."
3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if
you would like."
The nurse is acknowledging that the client is feeling especially down and offering to
be available for discussion or just to provide a presence. Telling the client not to cry and
suggesting a card game do not acknowledge the client's feelings and appear to trivialize
the situation. The response regarding suicide is judgmental and may discourage any
effort by the client to initiate a discussion.
,A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left
tibia. The client reveals a history of substance abuse. What is the primary consideration
for the nurse who is caring for this client?
1
Confronting the client about substance abuse
2
Avoiding calling attention to the client's drug abuse
3
Determining the amount and time of last use of the
substance 4
Realizing that this client will need more pain medication than a nonabuser
3
Determining the amount and time of last use of the substance
Determining the amount and last use of the substance is the priority. Nurses should
base their treatment of withdrawal symptoms on the time and amount of last use.
Confronting the client is not the nurse's responsibility at this time. The client must be
helped to recognize that a problem with drugs exists, but this is not the priority.
Because of cross-tolerance the client may need larger doses of analgesia for pain relief
than a nonabuser would, but this is not the priority.
, A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar
disorder, manic phase. In which type of room should the nurse tell the admissions clerk to
place this client?
1
Private
2
Isolation
3
Semi-private
4
Negative-airflow
1
Private
The client who is manic needs a nonstimulating environment. A person who is bipolar is
not contagious and does not require an isolation room. The presence of another person in
the room is considered stimulating and may interfere with the rest and sleep of both
clients. A client who is bipolar does not need a negative-airflow room. This type of room is
appropriate for a client with a communicable disease, such as tuberculosis, that requires
airborne precautions.