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A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?
- A. "I will ask the physician to prescribe medication for you."?
- B. "That must have been a very difficult and frightening experience. It might be helpful to talk about it."?
- C. "In the future, you might walk your dog in a more populated area or hire someone else to take over this task."?
- D. "Have you thought of moving to a safer neighborhood?"?
Correct Answer: B
Rationale: Choice B is the best response as it provides empathy and encourages the client to talk about her experience, which can be therapeutic. This approach validates the client's feelings and offers support. By acknowledging the difficulty and fear experienced by the client, the nurse opens the door for the client to express her emotions and begin the process of coping with the trauma. Choices A, C, and D do not address the emotional impact of the traumatic event or provide an opportunity for the client to express her feelings and concerns. Choice A immediately jumps to medication without exploring other supportive interventions. Choice C focuses on practical solutions without addressing the client's emotional needs. Choice D suggests a drastic solution without considering the client's emotional state or preferences.
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What can the nurse instruct the mother of a teething 9-month-old infant to relieve discomfort?
- A. Rub the infant's gums with baby aspirin dissolved in water.
- B. Obtain an over-the-counter (OTC) topical medication for gum pain relief.
- C. Schedule an appointment with a dentist for a dental evaluation.
- D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast.
Correct Answer: D
Rationale: Teething in infants can cause discomfort, but it is a normal process. Symptoms may include nighttime awakening, daytime restlessness, excess drooling, and temporary loss of appetite. The recommended approach to relieve teething discomfort includes providing cool liquids, a Popsicle, or hard foods like dry toast for chewing. These items can help soothe the infant's gums. Rubbing the gums with baby aspirin dissolved in water is not recommended as it can be harmful. OTC topical medications are unnecessary for teething discomfort. Scheduling a dental evaluation is not required solely for teething. It's important to avoid home remedies like baby aspirin and opt for safer options like cool liquids. If necessary, acetaminophen (Tylenol) can be used under healthcare provider guidance to alleviate discomfort.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- A. Take the blood pressure, pulse, and temperature
- B. Ask the client to rate his pain on a scale of 0-5
- C. Watch the client's facial expression
- D. Ask the client if he is in pain
Correct Answer: B
Rationale: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. This method provides a more standardized and quantifiable measure of pain compared to subjective observations like facial expressions (choice C) or direct questioning (choice D). Monitoring vital signs (choice A) can be part of pain assessment but is not as specific or reliable as asking the client to self-report pain intensity.
A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that
- A. Multiple drug use is common.
- B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms.
- C. Combining alcohol and barbiturates can be dangerous due to their combined depressant effects.
- D. Assessment and intervention are more complex with multiple drug use due to the synergistic effects.
Correct Answer: B
Rationale: When caring for a client with Multiple Drug Use, it is important to understand that individuals may use more than one drug simultaneously or sequentially to enhance the effect of a particular drug or to relieve withdrawal symptoms. This practice is common among substance users. For example, heroin users may also consume alcohol, marijuana, or benzodiazepines. Combining drugs can have various effects, such as intensifying intoxication or alleviating withdrawal symptoms. It is crucial to recognize that multiple drug use can complicate assessment and intervention due to the diverse effects of different substances on the client's health. Option A is incorrect as multiple drug use is indeed common, not uncommon. Option C is incorrect because combining alcohol and barbiturates can be dangerous due to their combined depressant effects. Option D is incorrect because multiple drug use complicates assessment and intervention rather than making them easier, as the effects of different drugs on the client need to be carefully considered.
What is the first exercise that should be performed by a client who had a mastectomy?
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct Answer: D
Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.
After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:
- A. verbalizing the implied.
- B. seeking consensual validation.
- C. encouraging evaluation.
- D. suggesting collaboration.
Correct Answer: B
Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.