Nokea
A client is suspected of having posttraumatic stress disorder. Which problem is the most important for the nurse to assess?
- A. panic attacks
- B. anorexia
- C. suicide
- D. short-term memory loss
Correct Answer: C
Rationale: Suicide risk is the most critical to assess in PTSD due to high rates of suicidal ideation and attempts.
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The nurse on the cardiac unit notes that a client recovering from a myocardial infarction appears worried and irritable. The client says, 'I am worried about my business. I run a restaurant and am used to working 70 hours a week. I am worried about whether I will be able to handle the stress once I am back there.' Which response by the nurse is best?
- A. Give the client a list of complementary therapies related to relaxation and say, 'Pretend this is a menu. Which of these would you like to order for yourself?'
- B. You might find it interesting to attend the cardiac cooking class the dietitian gives before you are discharged.
- C. Who is supposed to be taking care of the restaurant while you are here in the hospital?
- D. Hand the client the television control and say, 'Sometimes when I have a lot on my mind, I watch a movie. It makes me feel better.'
Correct Answer: A
Rationale: Providing a list of relaxation therapies directly addresses the client’s stress concerns and empowers them to choose coping strategies, aligning with their expressed worries about returning to a high-stress job. Other options are less relevant to stress management.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
- A. monitor the airway and be prepared to provide suction if needed
- B. continuously observe vital signs and cardiac function on the monitor
- C. provide support and safe positioning to the client's arms and legs during the seizure
- D. record the type, frequency, duration, and amount of movement induced by the seizure
Correct Answer: A
Rationale: Airway management is the priority during ECT due to the risk of aspiration or respiratory compromise during induced seizures.
A client who is in halo traction states to the visiting nurse, 'I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is.' Which therapeutic response should the nurse make to the client?
- A. If I were you, I would have had the surgery rather than suffer like this.
- B. No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously.
- C. Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around.
- D. Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think?
Correct Answer: C
Rationale: In option 3, the nurse employs empathy and reflection. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction. In option 1, the nurse undermines the client's faith in the medical treatment being employed by giving advice that is insensitive and unprofessional. In option 2, the nurse provides a social response that contains emotionally charged language that could increase the client's anxiety. In option 4, the nurse uses excessive questioning and gives advice, which is nontherapeutic.
The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?
- A. The client is experiencing delusions of messianic grandeur.
- B. The client believes that the world is ending on a specific date.
- C. The client is experiencing persistent pain after the resolution of herpes zoster.
- D. The client is experiencing blindness without an identified physical cause.
Correct Answer: D
Rationale: Conversion disorder involves physical symptoms, like blindness, without a medical cause, often linked to psychological stress. Blindness without a physical cause is a classic example, unlike delusions or unrelated pain.
The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?
- A. Staying with the client
- B. Distracting the client with television
- C. Interpreting the arterial blood gas report
- D. Encouraging the client to cough and breathe deeply
Correct Answer: A
Rationale: Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress.