Nokea
The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?
- A. Educate the client on managing stress.
- B. Teach the client to maintain a balanced diet.
- C. Instruct the client to have regular health checkups.
- D. Ask the client to use sunscreen when working outdoors.
Correct Answer: A
Rationale: The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.
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Which behavior by the client exhibits denial after a recent diagnosis?
- A. Attempts to minimize the illness
- B. Lacks an emotional response to the illness
- C. Refuses to discuss the condition with the client's spouse
- D. Expresses displeasure with the prescribed activity program
Correct Answer: A
Rationale: The correct answer is 'Attempts to minimize the illness.' This behavior is a classic sign of denial, where the individual tries to downplay the seriousness of the illness to cope with it. By minimizing the illness, the client avoids facing the reality of the situation, which is characteristic of denial. Lacking an emotional response to the illness suggests suppression of emotions rather than denial. Refusing to discuss the condition with the spouse may stem from other issues like relationship strain or fear of causing distress, but it doesn't directly indicate denial. Expressing displeasure with the prescribed activity program typically reflects displaced anger, not denial of the illness.
When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
- A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
- B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
- C. 'I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
- D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct Answer: A
Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
The client has a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?
- A. Mastery of colostomy care techniques
- B. Readiness to accept an altered body function
- C. Awareness of community resources available
- D. Understanding necessary dietary modifications
Correct Answer: B
Rationale: The most crucial client outcome for successful adjustment to a new colostomy is the readiness to accept an altered body function. Acceptance of changes in body image and function is essential to facilitate mastery of colostomy care techniques and optimal utilization of community resources. Without readiness to accept the altered body function, the client may not be open to learning and adopting necessary changes, hindering the achievement of long-term goals. Understanding dietary modifications, while important, is secondary to the fundamental acceptance of the altered body function in the process of adjusting to a new colostomy.
Which nursing action promotes psychosocial development for a newborn?
- A. Washing hands before holding the newborn
- B. Measuring the newborn using an approved length board
- C. Weighing the newborn on the same scale during hospitalization
- D. Placing the newborn in the mother's arms during the first hour of life
Correct Answer: D
Rationale: Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being.
Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.
The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?
- A. Domestic abuse
- B. Hydatidiform mole
- C. Excessive exercise
- D. Thrombocytopenic purpura
Correct Answer: A
Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.