Nokea
A 12-year-old client is seen in the health care clinic. During the assessment, which finding would suggest to the nurse that the client is experiencing a disruption in the development of self-concept?
- A. The child has many friends.
- B. The child has a part-time babysitting job.
- C. The child has an intimate relationship with a significant other.
- D. The child enjoys playing chess and mastering new skills with this game.
Correct Answer: C
Rationale: The formation of an intimate relationship would not be expected until young adulthood. Friends are important and appropriate for members of this age group. A sense of industry is appropriate for this age group, and it may be exhibited by the child having a part-time job. The increase in self-esteem associated with skill mastery is an important part of development for the school-age child.
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The nurse is caring for a client with a diagnosis of terminal cancer of the throat. The family tells the nurse that they have spoken to the primary health care provider regarding taking their loved one home. The nurse plans to coordinate discharge planning. Which service would be most supportive to the client and the family?
- A. Hospice care
- B. The American Cancer Society
- C. The American Lung Association
- D. Local religious and social organizations
Correct Answer: A
Rationale: Hospice care provides an environment that emphasizes caring rather than curing; the emphasis is on palliative care. One of the major goals of hospice care is that clients be free of pain and other symptoms that do not allow them to maintain a quality life. An interdisciplinary approach is used. Although the remaining options may be helpful, they are not the most supportive of the options provided.
The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.)
- A. Keep the voice even throughout conversations.
- B. Explain the sounds in the environment.
- C. Decrease background noise before speaking.
- D. Stay in the client's field of vision.
- E. Identify self by name and staff position.
Correct Answer: A,B,C,D,E
Rationale: All options are appropriate: (A) Even voice tone ensures clarity; (B) Explaining sounds reduces confusion; (C) Reducing noise aids hearing; (D) Staying in the field of vision supports communication; (E) Identifying self orients the client. These interventions enhance safety and interaction.
A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?
- A. The client is projecting by insisting that walking is the rehabilitation goal.
- B. To speed acceptance, the client needs reinforcement that he will not walk again.
- C. Denial can be protective while the client deals with the anxiety created by the new disability.
- D. The client needs to move through the grieving process rapidly to benefit from rehabilitation.
Correct Answer: C
Rationale: During the adjustment period that occurs the first few weeks after a spinal cord injury, clients may use denial as a defense mechanism. Denial may decrease anxiety temporarily, and it is a normal part of grieving. After the spinal shock resolves, the prolonged or excessive use of denial may impair rehabilitation. However, rehabilitation programs include psychological counseling to deal with denial and grief.
When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic?
- A. Well, I can see you never got to the stop smoking clinic.
- B. Now that your secret is out, may we decide what you are going to do?
- C. Did you explore the stop smoking program at the senior citizens center?
- D. I wonder if you realize that by smoking you are slowly killing yourself.
Correct Answer: C
Rationale: Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.