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The home health nurse is scheduled to visit a client at home and found out that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care? How much do you use and what effect does it have on you How long did you think you could take these drugs without someone finding out Why did you get started on these drugs? The nurse does not ask any questions in fear that the client is in denial and will throw the nurse out of the home. Question 1 Explanation: ANSWER: How much do you use and what effect does it have on you ; RATIONALE: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being judgmental and direct. Question 2 Wrong The nurse assigned a nursing student to formulate a post procedure plan of care to a client who undergone bone biopsy. The nurse determines that the student needs to research further about post procedure care if which inaccurate intervention is documented? Monitoring Site for swelling, bleeding or hematoma Elevating the limb for 24 hours Monitoring Vital signs every 4 hours Administering Narcotic Analgesic intramuscularly Question 2 Explanation: ANSWER: Administering Narcotic Analgesic intramuscularly. ; RATIONALE: After biopsy the client usually requires mild analgesic. A nurse is in charge to care for a young female client, a victim of sexual assault. The nurse completed the physical assessment and important evidence was gathered. The nurse notes that the client is withdrawn, confused, and at times physically immobile. This behavior are interpreted by the nurse as: Signs of depression Indicative of the need for hospital admission Evidence that the client is a high suicide risk Normal reaction to a devastating event Question 3 Explanation: ANSWER: Normal reaction to a devastating event ; RATIONALE: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event. Question 1 Wrong The home health nurse is scheduled to visit a client at home and found out that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care?

How much do you use and what effect does it have on you How long did you think you could take these drugs without someone finding out Why did you get started on these drugs? The nurse does not ask any questions in fear that the client is in denial and will throw the nurse out of the home. Question 1 Explanation: ANSWER: How much do you use and what effect does it have on you ; RATIONALE: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being judgmental and direct. Question 2 Wrong The nurse assigned a nursing student to formulate a post procedure plan of care to a client who undergone bone biopsy. The nurse determines that the student needs to research further about post procedure care if which inaccurate intervention is documented? Monitoring Site for swelling, bleeding or hematoma Elevating the limb for 24 hours Monitoring Vital signs every 4 hours Administering Narcotic Analgesic intramuscularly Question 2 Explanation: ANSWER: Administering Narcotic Analgesic intramuscularly. ; RATIONALE: After biopsy the client usually requires mild analgesic. Question 3 Wrong A nurse is in charge to care for a young female client, a victim of sexual assault. The nurse completed the physical assessment and important evidence was gathered. The nurse notes that the client is withdrawn, confused, and at times physically immobile. This behavior are interpreted by the nurse as: Signs of depression Indicative of the need for hospital admission Evidence that the client is a high suicide risk Normal reaction to a devastating event Question 3 Explanation: ANSWER: Normal reaction to a devastating event ; RATIONALE: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event. Question 4 Wrong A nurse is making rounds; he enters a clients room. The client is begging to the nurse to be released from the hospital. The nurse checks the clients records and found out that the client was voluntarily admitted two days ago with a diagnosis of an anxiety disorder. Which of the following will the nurse take? Persuade the client to stay a few more days Contact the physician Call the clients family

Tell the client that discharge is not possible at this time Question 4 Explanation: ANSWER: Contact the physician ; RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states requires that the client submit a written release notice to the facility staff, who reevaluates the clients condition for possible conversion to involuntary status, according to criteria established by law. Question 5 Wrong A nurse enters the female client room to administer medication. Inside the room, the client is in manic state. She is naked and making sexual remarks and gestures toward the nurse. The best initial nursing action is to: Approach the client and insist that she has to put on her clothes Quietly approach the client and assist her in getting dressed Ask the other nurse to calm the client Confront the client on the inappropriateness of her behavior and offer her a time-out Question 5 Explanation: ANSWER: Quietly approach the client and assist her in getting dressed ; RATIONALE: A person who is experiencing mania lacks insight and judgment, has poor impulse control and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. Question 1 Wrong The home health nurse is scheduled to visit a client at home and found out that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care? How much do you use and what effect does it have on you How long did you think you could take these drugs without someone finding out Why did you get started on these drugs? The nurse does not ask any questions in fear that the client is in denial and will throw the nurse out of the home. Question 1 Explanation: ANSWER: How much do you use and what effect does it have on you ; RATIONALE: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being judgmental and direct. Question 2 Wrong The nurse assigned a nursing student to formulate a post procedure plan of care to a client who undergone bone biopsy. The nurse determines that the student needs to research further about post procedure care if which inaccurate intervention is documented? Monitoring Site for swelling, bleeding or hematoma Elevating the limb for 24 hours Monitoring Vital signs every 4 hours

Administering Narcotic Analgesic intramuscularly Question 2 Explanation: ANSWER: Administering Narcotic Analgesic intramuscularly. ; RATIONALE: After biopsy the client usually requires mild analgesic. Question 3 Wrong A nurse is in charge to care for a young female client, a victim of sexual assault. The nurse completed the physical assessment and important evidence was gathered. The nurse notes that the client is withdrawn, confused, and at times physically immobile. This behavior are interpreted by the nurse as: Signs of depression Indicative of the need for hospital admission Evidence that the client is a high suicide risk Normal reaction to a devastating event Question 3 Explanation: ANSWER: Normal reaction to a devastating event ; RATIONALE: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event. Question 4 Wrong A nurse is making rounds; he enters a clients room. The client is begging to the nurse to be released from the hospital. The nurse checks the clients records and found out that the client was voluntarily admitted two days ago with a diagnosis of an anxiety disorder. Which of the following will the nurse take? Persuade the client to stay a few more days Contact the physician Call the clients family Tell the client that discharge is not possible at this time Question 4 Explanation: ANSWER: Contact the physician ; RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states requires that the client submit a written release notice to the facility staff, who reevaluates the clients condition for possible conversion to involuntary status, according to criteria established by law. Question 5 Wrong A nurse enters the female client room to administer medication. Inside the room, the client is in manic state. She is naked and making sexual remarks and gestures toward the nurse. The best initial nursing action is to: Approach the client and insist that she has to put on her clothes Quietly approach the client and assist her in getting dressed Ask the other nurse to calm the client

Confront the client on the inappropriateness of her behavior and offer her a time-out Question 5 Explanation: ANSWER: Quietly approach the client and assist her in getting dressed ; RATIONALE: A person who is experiencing mania lacks insight and judgment, has poor impulse control and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. Question 6 Wrong On the day before discharge from the hospital, the nurse provides instruction to the client who delivered a healthy baby by cesarean delivery. Which of the following statement if made by the client indicates a need for further instruction? I will notify the physician if I develop a fever. "I will begin abdominal exercises immediately. I will lift nothing heavier than the newborn infant for at least 2 weeks. I will turn on my side and push up with my arms to get out of bed. Question 6 Explanation: ANSWER: "I will begin abdominal exercises immediately. ; RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Question 1 Wrong The home health nurse is scheduled to visit a client at home and found out that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care? How much do you use and what effect does it have on you How long did you think you could take these drugs without someone finding out Why did you get started on these drugs? The nurse does not ask any questions in fear that the client is in denial and will throw the nurse out of the home. Question 1 Explanation: ANSWER: How much do you use and what effect does it have on you ; RATIONALE: Whenever the nurse employs an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being judgmental and direct. Question 2 Wrong The nurse assigned a nursing student to formulate a post procedure plan of care to a client who undergone bone biopsy. The nurse determines that the student needs to research further about post procedure care if which inaccurate intervention is documented? Monitoring Site for swelling, bleeding or hematoma Elevating the limb for 24 hours Monitoring Vital signs every 4 hours Administering Narcotic Analgesic intramuscularly Question 2 Explanation: ANSWER: Administering Narcotic Analgesic intramuscularly. ; RATIONALE: After biopsy the client usually requires mild analgesic.

Question 3 Wrong A nurse is in charge to care for a young female client, a victim of sexual assault. The nurse completed the physical assessment and important evidence was gathered. The nurse notes that the client is withdrawn, confused, and at times physically immobile. This behavior are interpreted by the nurse as: Signs of depression Indicative of the need for hospital admission Evidence that the client is a high suicide risk Normal reaction to a devastating event Question 3 Explanation: ANSWER: Normal reaction to a devastating event ; RATIONALE: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event. Question 4 Wrong A nurse is making rounds; he enters a clients room. The client is begging to the nurse to be released from the hospital. The nurse checks the clients records and found out that the client was voluntarily admitted two days ago with a diagnosis of an anxiety disorder. Which of the following will the nurse take? Persuade the client to stay a few more days Contact the physician Call the clients family Tell the client that discharge is not possible at this time Question 4 Explanation: ANSWER: Contact the physician ; RATIONALE: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states requires that the client submit a written release notice to the facility staff, who reevaluates the clients condition for possible conversion to involuntary status, according to criteria established by law. Question 5 Wrong A nurse enters the female client room to administer medication. Inside the room, the client is in manic state. She is naked and making sexual remarks and gestures toward the nurse. The best initial nursing action is to: Approach the client and insist that she has to put on her clothes Quietly approach the client and assist her in getting dressed Ask the other nurse to calm the client Confront the client on the inappropriateness of her behavior and offer her a time-out Question 5 Explanation: ANSWER: Quietly approach the client and assist her in getting dressed ; RATIONALE: A person who is experiencing mania lacks insight and judgment, has poor impulse

control and is highly excitable. The nurse must take control without creating increased stress or anxiety to the client. Question 6 Wrong On the day before discharge from the hospital, the nurse provides instruction to the client who delivered a healthy baby by cesarean delivery. Which of the following statement if made by the client indicates a need for further instruction? I will notify the physician if I develop a fever. "I will begin abdominal exercises immediately. I will lift nothing heavier than the newborn infant for at least 2 weeks. I will turn on my side and push up with my arms to get out of bed. Question 6 Explanation: ANSWER: "I will begin abdominal exercises immediately. ; RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Question 7 Wrong The nurse provided the client all the information needed about the upcoming endoscopic retrograde cholangiospancreatography procedure. The nurse determines that the client needs additional information if the client makes which of the following statements? Im glad some IV medication will be given to relax me I know I must sign the consent form Im glad I dont have to lie still for this procedure I hope the throat spray keeps me from gagging Question 7 Explanation: ANSWER: Im glad I dont have to lie still for this procedure ; RATIONALE: The client doest not have to lie still for ERCP, which takes about an hour to perform.