Nokea
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
- A. Arrange to change client care assignments.
- B. Explain that this behavior is expected.
- C. Discuss the appropriate use of 'time-out'.
- D. Explain that the child needs extra attention.
Correct Answer: B
Rationale: The correct answer is to explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool. Changing client care assignments (Choice A) is not necessary as the child's behavior is developmentally appropriate. Discussing the appropriate use of 'time-out' (Choice C) is not relevant in this situation as the child is displaying normal attachment behavior, not misbehavior. Explaining that the child needs extra attention (Choice D) may not be necessary as the child is likely seeking comfort from the familiar presence of the mother, which is a typical response in a stressful situation like being in a hospital environment.
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The nurse is performing an admission assessment for a non-English speaking patient who is from China. Which actions could the nurse take to enhance communication (select one that does not apply)?
- A. Use an electronic translation application.
- B. Use a telephone-based medical interpreter.
- C. Wait until an agency interpreter is available.
- D. Ask the patient's teenage daughter to interpret.
Correct Answer: D
Rationale: Electronic translation applications, telephone-based medical interpreters, and agency interpreters are all appropriate tools to enhance communication with non-English-speaking patients. However, asking the patient's teenage daughter to interpret is not recommended due to potential misinterpretation of crucial information during the admission assessment. While family members may be considered in the absence of a professional interpreter, there is a risk of misunderstanding or lack of sharing essential details. It is important to rely on trained interpreters to ensure accurate communication and avoid miscommunication or misinterpretation of critical information. Using gestures can be helpful, but over-exaggeration of gestures is unnecessary and may lead to confusion.
A client says, 'The doctors lied about me. They said I murdered my mother. You killed her. She died before I was born.' Which psychotic feature is the client experiencing?
- A. Ideas of grandeur
- B. Confusing illusions
- C. Persecutory delusions
- D. Auditory hallucinations
Correct Answer: C
Rationale: The client is experiencing persecutory delusions, as she believes that others are blaming her for negative actions. This is not about ideas of grandeur, which involve feelings of greatness or power. Confusing illusions refer to misinterpretation of stimuli, which is not present in this scenario. Auditory hallucinations involve hearing voices, which is not the case here. In this case, the client is delusional, but not hallucinating.
A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the nurse take first?
- A. Ask the patient what treatments are likely to help
- B. Massage the patient's abdomen until the pain subsides.
- C. Administer prescribed medications to decrease the cramping
- D. Offer to contact a curandero(a) for a visit to the patient
Correct Answer: A
Rationale: When a Hispanic patient presents with abdominal cramping related to empacho, it is crucial for the nurse to first understand the patient's cultural beliefs and preferences before initiating any interventions. In the case of a culture-bound syndrome like empacho, it is essential to acknowledge and respect the patient's cultural background. While options like administering medications, arranging a visit by a curandero(a), or providing massage may have potential benefits, assessing the patient's beliefs ensures that interventions are culturally sensitive and aligned with the patient's values. By engaging the patient in a discussion about potential treatments, the nurse can gather valuable information to tailor care effectively, promoting trust and collaboration in the healthcare process. This patient-centered approach enhances the quality of care and fosters a culturally competent nursing practice. Therefore, asking the patient about preferred treatments is the most appropriate initial action to address the patient's condition effectively.
After a mastectomy or a hysterectomy, a client may feel incomplete as a woman. Which statement would alert the nurse to this feeling in a client who has undergone a total hysterectomy?
- A. "I don't know who can help me during my recovery."
- B. "I feel washed out; there isn't much left."
- C. "I'm scared about the pain in recovery."
- D. "I can't wait to get home; I so want to see my grandchild."
Correct Answer: B
Rationale: The correct answer is "I feel washed out; there isn't much left." This statement suggests a feeling of emptiness or incompleteness after the surgical procedure. Concern about who can assist during recovery, fear of pain, or excitement to go home and see a grandchild are not indicative of feeling incomplete as a woman after a hysterectomy. These other statements focus on practical concerns, physical discomfort, and positive emotions, respectively.
A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the nurse take first?
- A. Ask the patient what treatments are likely to help
- B. Massage the patient's abdomen until the pain subsides.
- C. Administer prescribed medications to decrease the cramping
- D. Offer to contact a curandero(a) for a visit to the patient
Correct Answer: A
Rationale: When a Hispanic patient presents with abdominal cramping related to empacho, it is crucial for the nurse to first understand the patient's cultural beliefs and preferences before initiating any interventions. In the case of a culture-bound syndrome like empacho, it is essential to acknowledge and respect the patient's cultural background. While options like administering medications, arranging a visit by a curandero(a), or providing massage may have potential benefits, assessing the patient's beliefs ensures that interventions are culturally sensitive and aligned with the patient's values. By engaging the patient in a discussion about potential treatments, the nurse can gather valuable information to tailor care effectively, promoting trust and collaboration in the healthcare process. This patient-centered approach enhances the quality of care and fosters a culturally competent nursing practice. Therefore, asking the patient about preferred treatments is the most appropriate initial action to address the patient's condition effectively.