Nokea
A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to:
- A. Request that he explain to the group why he took personal items from peers
- B. Approach him when he is alone to inquire about his involvement in the incident
- C. Imply to him that you doubt his involvement in the incident and request his denial
- D. Confront him openly in group and request an apology
Correct Answer: B
Rationale: This answer is incorrect. There is no proof that he removed the missing items. This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
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The nurse is caring for a newborn with a suspected diaphragmatic hernia. The nurse should:
- A. Place the infant in Trendelenburg position
- B. Begin intravenous fluids immediately
- C. Maintain a quiet environment
- D. Position the infant on the affected side
Correct Answer: D
Rationale: Positioning a newborn with a diaphragmatic hernia on the affected side facilitates lung expansion on the unaffected side, improving respiration. Trendelenburg worsens breathing, and fluids are secondary.
The pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
- A. Administer oral griseofulvin on an empty stomach for best results.
- B. Discontinue drug therapy if food tastes funny.
- C. May discontinue medication when the child experiences symptomatic relief.
- D. Observe for headaches, dizziness, and anorexia.
Correct Answer: D
Rationale: Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. The child may experience symptomatic relief after 48-96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
- A. A reaction formation
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.
The nurse is teaching a client with a history of osteoarthritis about exercise. The nurse should tell the client to:
- A. Engage in low-impact activities
- B. Perform high-impact exercises
- C. Avoid all physical activity
- D. Lift heavy weights
Correct Answer: A
Rationale: Low-impact activities like swimming reduce joint stress in osteoarthritis, improving mobility and reducing pain.
Which of the following should be included in discharge teaching for a client with hepatitis C?
- A. He should take aspirin as needed for muscle and joint pain.
- B. He may become a blood donor when his liver enzymes return to normal.
- C. He should avoid alcoholic beverages during his recovery period.
- D. He should use disposable dishes for eating and drinking.
Correct Answer: C
Rationale: Alcohol should be avoided as it is detoxified by the liver, which is compromised in hepatitis C. Aspirin is hepatotoxic, blood donation is not allowed, and hepatitis C is not spread orally.