NRSG 347 Exam 3 Actual Exam Latest

NRSG 347 Exam 3 Actual Exam Latest | NRSG 347 Exam Questions and Correct Answers with Rationale Rated A+ An elderly client asks the nurse to kill the bugs that are crawling on the floor of her room. The nurse does not see any bugs and suspects the client is hallucinating. Which of the following statements by the nurse would be most appropriate?

• "it may seem to you that there are bugs crawling on the floor, but I

do not see any bugs"

• "I see them too. How should I kill them?"
• "can you tell me more about these bugs?"
• "what do the bugs look like?" -ANSWER-A) "it may seem to you

that there are bugs crawling on the floor, but I do not see any bugs"

Rationale:

• Correct answer. This response validates what the client is seeing.

To the client, a hallucination is real. However, the nurse must reorient the client to the appropriate reality and tur to restore the clients feelings of safety. You should not go with the hallucination and you should try to re-orient the patient to reality

• The nurse should not reinforce the hallucination
• The nurse should not encourage verbalize feeling during an active

hallucination

• it is not helpful to question or imply that the client is not seeing real

bugs

A client requires a lifesaving blood transfusion per hospital guidelines.The client refuses based on religious beliefs. It would be most appropriate for the nurse to take which of the following actions?

• Confirm with the client that the client understands the potential risks

for not having the blood transfusion

• Tell the client that, regardless of personal beliefs, the client has to

have the lifesaving transfusion.

• Call the Legal Department of the hospital immediately
• Try to gently encourage the client to change his or her mind -

ANSWER-A) Confirm with the client that the client understands the potential risks of not having the blood transfusion

Rationale:

• Correct answer. The nurse must be sure the client understands the

potential risks of not receiving the transfusion. Document that you went through the information and that the patient was still refusing treatment despite all the information was given

• Clients do have the right to refuse care on religious grounds
• Although the nurse may call the Legal Department at some future

time, this would not be the first course of action

• The nurse must be sure that the client comprehends the choice he

is making including risks and benefits. However the nurse does not want to coerce the client into changing his mind

The nurse on the inpatient psychiatric ward is caring for a client with known suicidal ideation. The 24 hour observer calls the nurse to report the client took off down the hall. The nurse is unable to immediately locate the client. Arrange the following actions in the order that is most appropriate

• notify security that the client has eloped, and provide a description

of the client

• notify the nurse manager
• notify other staff on the unit
• ask the observer in what direction the client headed -ANSWER-D,

C, A, B

Rationale

• asking the observer in which direction the client is headed is the

first step. This enables the nurse to give accurate information to staff, and if necessary security to help locate the client.

• Notifying other staff is the second step because they know the

client and are readily available to search locally

• Security is the third step because, although they are not

immediately on hand, they can have multiple people searching from different directions

• notifying the nurse manager is the last step, because the manager

may not be readily available. Your priority is locating the client

The nurse discovers a hospice client has expired. The family members are regrouping in the facility's waiting room. Which of the following actions by the nurse would be most appropriate?

• tell the family it would not be in their best interests to see their

loved one

• Encourage the family to view the body to help accept the situation
• Provide condolences to the family and offer them viewing time
• Tell the family, "I will give you some time to spend with your loved

one. Let me know if you need anything" -ANSWER-C) provide condolences to the family and offer them viewing time

Rationale

• It is not the nurses decision whether a family member wants to view

a body or not. This is a paternalistic attitude to be avoided in this setting

• The nurse should react to that particular family's needs or wishes,

and not encourage or discourage in either direction

C) Correct: the nurse acknowledges the loss, expresses sympathy,

and offers the viewing opportunity

• This statement assumes the family wants to view the body with out

the nurse inquiring first

The nurse monitors clients medications in a day program for a clients with disabilities. The nurse notices a teenage client who is frequently alone and often quiet. It would be most appropriate for the nurse to take which of the following actions?

• Allow the client alone time since the client seems to prefer this. The

client has the right to make this choice.

• Make an effort to interact with the client periodically
• Encourage the client to join a youth group
• Encourage other clients in the program to interact more frequently

with the client -ANSWER-C) Encourage the client to join a youth group

Rationale:

• It appears that the client has enough time alone, which could stunt

the client's social growth. It could also defeat the purpose of a day program, which is to promote interaction among clients. A goal of coming to a day program is social interaction

• Making an effort to interact with the client periodically does not lead

the client's personal growth. Therefore is not the best option

• Correct. Participating in a youth group can help teenage client with

a disability develop social skills, use support systems, and feel more like a typical teenager

• It would not be appropriate to talk about one client with another

clients for reasons of confidentiality and privacy

A client is experiencing a manic episode. It would be most appropriate for the nurse to perform which of the following interventions?

• Give the client materials to make a collage
• Encourage the client to use an exercise bike
• Encourage the client to attend a group about managing feelings
• Ask the client to play a board game with other clients -ANSWER-B)

Encourage the client to use an exercise bike