NURSING LEADERSHIP AND MANAGEMENT
DETAILED ANSWERS|LATEST
A registered nurse reviews a plan of care developed by a nursing student for a client with
depression and notes a nursing diagnosis of impaired nutrition: less than body
requirements. The registered nurse asks the student to revise the plan if which incorrect
intervention is documented?
a) offer small, high-calorie, high protein snacks frequently throughout the day and evening
b) offer high protein, high-calorie fluids frequently throughout the day and evening
c) remain with the client during meals
d) complete the food menu for the client during the depressed period - ANSWER D
- The client should be asked which foods or drinks she likes, and consultation with a dietitian
also may be done. The client is more likely to eat if the client has selected the foods and is
given foods that she likes. Options A, B, and C are appropriate interventions for the client
with depression with this nursing diagnosis.
A registered nurse reviews a plan of care developed by a nursing student for client with
paranoia and notes a nursing diagnosis of Disturbed thought process. The registered nurse
asks the nursing student to revise the plan if which incorrect intervention is documented?
a) sit with the client and hold the client's hand
b) avoid a warm approach when working with the client
c) use simple and clear language when speaking to the client
d) diffuse angry and hostile verbal attacks with a nondefensive stand - ANSWER A
- When caring for a paranoid client, the nurse must avoid any physical contact and should
not touch the client. The nurse should ask the client's permission if touch is necessary
because touch may be interpreted as a physical or sexual assault. The nurse would use
simple and clear language when speaking to the client to prevent misinterpretation and to
clarify the nurse's intent and actions. A warm approach is avoided because it can be
frightening to a person who needs emotional distance. A matter-of-fact consistency is
nonthreatening. Any anger and hostile verbal attacks need to be diffused with a
1
, nondefensive stand. The anger that a paranoid client expresses is often displaced, and when
the staff becomes defensive, anger of both the client and staff escalates. A nondefensive and
nonjudgmental attitude provides an attitude in which feelings can be explored more easily.
A registered nurse is discussing the characteristics of anorexia nervosa with a nursing
student. The registered nurse determines that the nursing student needs to further research
this disorder if the student states that which of the following is a characteristic of anorexia
nervosa?
a) personal relationships tend to become more superficial and distant
b) social contacts are avoided because of the fear of being invited to eat and being
discovered
c) the client is being preoccupied with food and meal planning, especially for others
d) the client will usually keep her weight near normal - ANSWER D
- As anorexia nervosa develops, personal relationships tend to become more superficial and
distant. Social contacts are avoided because of the fear of being invited to eat and being
discovered. The client is preoccupied with food and meal planning (especially for others),
personal caloric intake throughout the day, and methods to avoid eating. Anorexic persons
are likely to become very emaciated and will not maintain their near-normal body weight.
An experienced emergency department nurse observes a new nurse employed in the
emergency department obtain the equipment needed to draw a blood sample for a blood
alcohol level on a client. The experienced emergency department nurse intervenes if the
new nurse plans to use which item?
a) tourniquet
b) alcohol swabs
c) a blood-draw needle
d) a blood tube - ANSWER B
- Isopropyl alcohol or any antiseptic solution containing alcohol must not be used as a skin
preparation before a blood alcohol specimen is drawn. These agents may falsely elevate the
blood alcohol level and render the test invalid. Option A, C and D identify items needed to
obtain the blood specimen.
2
DETAILED ANSWERS|LATEST
A registered nurse reviews a plan of care developed by a nursing student for a client with
depression and notes a nursing diagnosis of impaired nutrition: less than body
requirements. The registered nurse asks the student to revise the plan if which incorrect
intervention is documented?
a) offer small, high-calorie, high protein snacks frequently throughout the day and evening
b) offer high protein, high-calorie fluids frequently throughout the day and evening
c) remain with the client during meals
d) complete the food menu for the client during the depressed period - ANSWER D
- The client should be asked which foods or drinks she likes, and consultation with a dietitian
also may be done. The client is more likely to eat if the client has selected the foods and is
given foods that she likes. Options A, B, and C are appropriate interventions for the client
with depression with this nursing diagnosis.
A registered nurse reviews a plan of care developed by a nursing student for client with
paranoia and notes a nursing diagnosis of Disturbed thought process. The registered nurse
asks the nursing student to revise the plan if which incorrect intervention is documented?
a) sit with the client and hold the client's hand
b) avoid a warm approach when working with the client
c) use simple and clear language when speaking to the client
d) diffuse angry and hostile verbal attacks with a nondefensive stand - ANSWER A
- When caring for a paranoid client, the nurse must avoid any physical contact and should
not touch the client. The nurse should ask the client's permission if touch is necessary
because touch may be interpreted as a physical or sexual assault. The nurse would use
simple and clear language when speaking to the client to prevent misinterpretation and to
clarify the nurse's intent and actions. A warm approach is avoided because it can be
frightening to a person who needs emotional distance. A matter-of-fact consistency is
nonthreatening. Any anger and hostile verbal attacks need to be diffused with a
1
, nondefensive stand. The anger that a paranoid client expresses is often displaced, and when
the staff becomes defensive, anger of both the client and staff escalates. A nondefensive and
nonjudgmental attitude provides an attitude in which feelings can be explored more easily.
A registered nurse is discussing the characteristics of anorexia nervosa with a nursing
student. The registered nurse determines that the nursing student needs to further research
this disorder if the student states that which of the following is a characteristic of anorexia
nervosa?
a) personal relationships tend to become more superficial and distant
b) social contacts are avoided because of the fear of being invited to eat and being
discovered
c) the client is being preoccupied with food and meal planning, especially for others
d) the client will usually keep her weight near normal - ANSWER D
- As anorexia nervosa develops, personal relationships tend to become more superficial and
distant. Social contacts are avoided because of the fear of being invited to eat and being
discovered. The client is preoccupied with food and meal planning (especially for others),
personal caloric intake throughout the day, and methods to avoid eating. Anorexic persons
are likely to become very emaciated and will not maintain their near-normal body weight.
An experienced emergency department nurse observes a new nurse employed in the
emergency department obtain the equipment needed to draw a blood sample for a blood
alcohol level on a client. The experienced emergency department nurse intervenes if the
new nurse plans to use which item?
a) tourniquet
b) alcohol swabs
c) a blood-draw needle
d) a blood tube - ANSWER B
- Isopropyl alcohol or any antiseptic solution containing alcohol must not be used as a skin
preparation before a blood alcohol specimen is drawn. These agents may falsely elevate the
blood alcohol level and render the test invalid. Option A, C and D identify items needed to
obtain the blood specimen.
2
