Nokea
A 24-year-old female client is scheduled for surgery in the morning. What is the primary responsibility of the nurse?
- A. Taking the vital signs
- B. Obtaining the permit
- C. Explaining the procedure
- D. Checking the lab work
Correct Answer: A
Rationale: The primary responsibility of the nurse is to take the vital signs before any surgery. This action helps assess the client's baseline condition and identify any abnormalities that need addressing before the procedure. Obtaining the permit (choice B) is typically handled by administrative staff, explaining the procedure (choice C) is usually done by the healthcare provider performing the surgery, and checking the lab work (choice D) is often part of the pre-operative assessment conducted by the healthcare provider. Therefore, in this context, these actions are not the primary responsibility of the nurse.
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A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. "You have nothing to worry about. You are in a safe place. Try to relax."?
- B. "Has anything happened recently or in the past that might have triggered these feelings?"?
- C. "We have given you a medication that helps to decrease feelings of anxiety."?
- D. "Take some deep breaths and try to calm down."?
Correct Answer: B
Rationale: Choice B is the best response as it shows empathy, acknowledges the patient's feelings, and opens the door for discussion about potential triggers for anxiety. This approach helps the patient explore the root cause of his anxiety and provides an opportunity for therapeutic communication. Choice A dismisses the patient's feelings and offers false reassurance, which may not address the underlying issue. Choices C and D do not encourage the patient to express his emotions or delve into the reasons behind his anxiety, hindering the therapeutic process.
What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?
- A. Discussing the repetitive actions.
- B. Insisting the client not perform the repetitive act.
- C. Informing the client that the act is not necessary.
- D. Encouraging daily exercise.
Correct Answer: D
Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
- A. Have decreased anxiety.
- B. Talk to the nurse for 10 minutes.
- C. Sit quietly for 30 minutes.
- D. Develop an adaptive coping mechanism.
Correct Answer: B
Rationale: When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
- A. inquire about the possibility of sexual abuse.
- B. ask about the types of foods the child is eating.
- C. request to see the type of bottle used for feedings.
- D. question the parent about objects the child plays with.
Correct Answer: A
Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.
In the context of milieu therapy, what is its primary purpose?
- A. exploring the client's perception of reality
- B. enhancing social interaction abilities
- C. addressing maladaptive behaviors
- D. providing routine daily experiences
Correct Answer: D
Rationale: Milieu therapy aims to provide routine daily experiences to clients. By offering a structured and predictable environment, it helps individuals feel safe and secure, reducing disruptive behaviors. Exploring the client's perception of reality (choice A) may be part of therapy but not the primary focus. Enhancing social interaction abilities (choice B) and addressing maladaptive behaviors (choice C) are important aspects of therapy but not the primary purpose of milieu therapy.