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Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?
- A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
- B. A client reads a story about a traumatic event and then visualizes the result
- C. A client focuses on a negative thought in their mind while tapping their fingers
- D. None of the above
Correct Answer: A
Rationale: Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.
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Which client is most likely to be at risk for spiritual distress?
- A. Roman Catholic woman considering an abortion
- B. Jewish man considering hospice care for his wife
- C. Seventh-Day Adventist who needs a blood transfusion
- D. Muslim man who needs a total knee replacement
Correct Answer: A
Rationale: The correct answer is the Roman Catholic woman considering an abortion. In the Roman Catholic faith, abortion is strictly prohibited, so making a decision regarding abortion can bring about spiritual distress. The Jewish faith does not have restrictions on hospice care. It is Jehovah's Witnesses, not Seventh-Day Adventists, who do not accept blood transfusions due to religious beliefs. Additionally, there are no religious prohibitions against joint replacement in the Muslim faith.
The mother of a 5-month-old is being educated about her baby's nutrition by the nurse. Which statement by the mother indicates the need for further teaching?
- A. ''I'm going to try feeding my baby some rice cereal.''
- B. ''When he wakes at night for a bottle, I feed him.''
- C. ''I dip his pacifier in honey so he'll take it.''
- D. ''I keep formula in the refrigerator for 24 hours.''
Correct Answer: C
Rationale: The correct answer is ''I dip his pacifier in honey so he'll take it.'' This statement indicates a need for further teaching because honey should be avoided in infants due to the risk of infant botulism. Honey may contain spores of Clostridium botulinum, which can lead to serious illness in infants as they lack the necessary digestive enzymes to eliminate the spores. Feeding rice cereal, responding to night-time feedings, and storing formula in the refrigerator are appropriate practices for infant care, indicating understanding of the instructions.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
- A. Consult with the pharmacist about the need to continue the medication.
- B. Administer the antihypertensive medication as prescribed preoperatively.
- C. Withhold the medication until the client is fully alert and vital signs are stable.
- D. Contact the health care provider to renew the prescription for the medication.
Correct Answer: D
Rationale: In this scenario, the nurse has noted that an antihypertensive medication prescribed preoperatively is missing from the postoperative prescriptions. It is essential to renew preoperative medications postoperatively. Therefore, the correct action for the nurse to take is to contact the health care provider to renew the prescription for the antihypertensive medication. Consulting with the pharmacist about the need to continue the medication is not appropriate in this situation as pharmacists do not prescribe or renew medications. Administering the antihypertensive medication as prescribed preoperatively without a current prescription poses a risk to the client's safety. Withholding the medication until the client is fully alert and vital signs are stable does not address the issue of the missing prescription and delays the client's necessary treatment.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct Answer: C
Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option D) as the catheter could be inserted easily.
Which of the following is an example of an opioid?
- A. Mescaline
- B. Diazepam
- C. Phenobarbital
- D. Methadone
Correct Answer: D
Rationale: Opioids are a type of drug classified as narcotics. Nurses working with clients with substance abuse issues often encounter opioids. Opioids have the potential for addiction. Examples of opioids include methadone, codeine, morphine, and hydromorphone. Mescaline (Choice A) is a hallucinogen, not an opioid. Diazepam (Choice B) is a benzodiazepine used to treat anxiety and other conditions, not an opioid. Phenobarbital (Choice C) is a barbiturate used to treat seizures and insomnia, not an opioid.