Nokea
A 16-year-old client diagnosed with diabetes is admitted for hyperglycemia. The client states, 'I'm fed up with having my life ruled by diets, doctors' prescriptions, and machines!' Based on this assessment data, which is the priority client concern?
- A. A chronic illness
- B. A personal crisis
- C. Feelings of loss of control
- D. Lack of understanding about nutrition
Correct Answer: C
Rationale: Adolescents strive for identity and independence, and the situation describes a common fear of loss of control. Therefore, the priority problem relates to these feelings of loss of control. Although the child has a chronic illness and may be experiencing a personal crisis, the child's statement focuses on loss of control. There is no information in the question that indicates a lack of knowledge.
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A 37-year-old woman with a history of fibroids and menorrhagia that have not been responsive to hormonal treatments is admitted with severe menorrhagia resulting in anemia. She also has depression and pelvic pain. She is crying and states, 'I don't know what to do"?my primary health care provider is recommending a hysterectomy, but I haven't had children yet!' Which response would the nurse provide?
- A. There are so many children up for adoption, looking for a mother.'
- B. This must feel so difficult for you. Children are really important to you?'
- C. This must feel so difficult for you. Although Children should not be important to you.'
- D. Believe me when I tell you that kids are so difficult to raise"?you're better off without them.'
Correct Answer: B
Rationale: The correct response is to acknowledge the client's feelings and provide an open-ended question to encourage further expression. By expressing empathy and understanding, the nurse can create a supportive environment for the client. This approach allows the client to explore her emotions and concerns freely. Option A, suggesting adoption, may come across as dismissive of the client's current emotional state and may not address her immediate needs. Option D is insensitive and dismissive of the client's feelings and desires regarding having children. It is important to avoid making assumptions or judgments about the client's situation. Option C is a duplicate of Option B, and while it shows empathy, it lacks variety in communication, which may limit the depth of the conversation and the nurse's understanding of the client's needs.
A client who is in labor has human immunodeficiency virus (HIV) and states to the nurse, 'I know I will have a sick-looking baby.' Which appropriate therapeutic response should the nurse make?
- A. You are very sick, but your baby may not be.'
- B. All babies are beautiful. I am sure your baby will be too.'
- C. You have concerns about how HIV will affect your baby?'
- D. There is no reason to worry. Our neonatal unit offers the latest treatments available.'
Correct Answer: C
Rationale: Option 3 is the most therapeutic response, and it will elicit the best information. It addresses the therapeutic communication technique of paraphrasing. Option 3 also is an open-ended response that will provide an opportunity for the client to verbalize her concerns. Parents need to know that their baby will not look sick from HIV at birth and that there may be a period of uncertainty before it is known whether the baby has acquired the infection. Options 1 and 2 provide false reassurances. The client should not be told that there is no reason to worry.
A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?
- A. Suggest that the client arrange for help at home
- B. Ask the client to describe her concerns more fully
- C. Tell the client to speak to her primary health care provider about her concerns
- D. Recommend that the client schedule times when family members can assist her
Correct Answer: B
Rationale: When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.
A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, 'I feel like I've lost my sense of power.' Which response would the nurse give?
- A. Hair does not empower a person.'
- B. Losing power seems important to you.'
- C. Knowledge is power; I'll give you some pamphlets to read.'
- D. Hair loss is common; it will grow back, so you should not worry.'
Correct Answer: B
Rationale: The correct response is, 'Losing power seems important to you.' This response acknowledges the client's feelings and provides an opportunity for further discussion. Choice A is confrontational and dismissive, potentially shutting down communication. Choice C offers pamphlets, which may be seen as dismissing the client's concerns and avoiding engaging in a conversation. Choice D minimizes the client's feelings and may discourage further expression of emotions. By choosing option B, the nurse shows empathy and encourages the client to explore their emotions in a supportive environment.
Which basic principle of Alcoholics Anonymous (AA) should a client with alcohol use disorder follow?
- A. Spouses should attend Al-Anon meetings.
- B. It is a commitment to focus on long-term goals.
- C. Amends must be made to each person who has been harmed.
- D. People have the power to overcome alcoholism if they truly want to stop drinking.
Correct Answer: C
Rationale: The correct answer is that amends must be made to each person who has been harmed. This principle is reflected in the eighth step of the 12 steps of AA, which involves making a list of all persons harmed and being willing to make amends to them. It is a fundamental principle of AA to address past harms and seek to rectify them. Choice A is incorrect because spouses attending Al-Anon meetings is not a basic principle of AA; it is a support group for family members of individuals with alcohol use disorder. Choice B is incorrect because while focusing on long-term goals can be beneficial, AA emphasizes taking one day at a time rather than committing to long-term goals. Choice D is incorrect because AA teaches that individuals struggling with alcoholism are powerless over their addiction and need to rely on a higher power rather than solely their willpower to overcome it.