Nokea
A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?
- A. The client is projecting by insisting that walking is the rehabilitation goal.
- B. To speed acceptance, the client needs reinforcement that he will not walk again.
- C. Denial can be protective while the client deals with the anxiety created by the new disability.
- D. The client needs to move through the grieving process rapidly to benefit from rehabilitation.
Correct Answer: C
Rationale: During the adjustment period that occurs the first few weeks after a spinal cord injury, clients may use denial as a defense mechanism. Denial may decrease anxiety temporarily, and it is a normal part of grieving. After the spinal shock resolves, the prolonged or excessive use of denial may impair rehabilitation. However, rehabilitation programs include psychological counseling to deal with denial and grief.
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A client with a diagnosis of depression states to the nurse, 'I should have died. I've always been a failure.' Which therapeutic response should the nurse make to the client?
- A. You don't see anything positive?
- B. You still have a great deal to live for.
- C. Feeling like a failure is part of your illness.
- D. You've been feeling like a failure for some time now?
Correct Answer: D
Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate the exploration of the client's expressed feelings.
The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?
- A. Support in maintaining a sense of control
- B. Less pain and anxiety than with a normal labor
- C. A sense of satisfaction regarding her quick labor
- D. Fewer fears regarding the effect of labor on the newborn infant
Correct Answer: A
Rationale: The client experiencing a precipitous labor may have more difficulty maintaining control because of the abrupt onset and quick progression of the labor. This may be very different from previous labor experiences; therefore, the client needs support from the nurse to understand and adapt to the rapid progression. The contractions often increase in intensity very quickly, which adds to the client's pain, anxiety, and lack of control. The client may also have an increased amount of concern about the effect of the labor on the newborn infant. A lack of control over the situation in combination with increased pain and anxiety can result in a decreased level of satisfaction with the labor and delivery experience.
A 12-year-old client is seen in the health care clinic. During the assessment, which finding would suggest to the nurse that the client is experiencing a disruption in the development of self-concept?
- A. The child has many friends.
- B. The child has a part-time babysitting job.
- C. The child has an intimate relationship with a significant other.
- D. The child enjoys playing chess and mastering new skills with this game.
Correct Answer: C
Rationale: The formation of an intimate relationship would not be expected until young adulthood. Friends are important and appropriate for members of this age group. A sense of industry is appropriate for this age group, and it may be exhibited by the child having a part-time job. The increase in self-esteem associated with skill mastery is an important part of development for the school-age child.
A client who is experiencing suicidal thoughts shares with the nurse that, 'I was awake most of the night. It just doesn't seem worth it anymore. Why not just end it all?' Which response should the nurse make to best further assess the client?
- A. Did you sleep at all last night?
- B. Tell me what you mean by that.
- C. I know you have had a stressful night.
- D. I'm sure that your family is worried about you.
Correct Answer: B
Rationale: Option 2 allows the client the opportunity to tell the nurse more about what his or her current thoughts are. Option 1 changes the subject and may block communication. Although option 3 offers empathy to the client, it does not further assess the client. Option 4 is false reassurance and may block communication.
A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client's anxiety, should now be limited?
- A. Radio
- B. Television
- C. Family visitors
- D. Antianxiety medications
Correct Answer: D
Rationale: Antianxiety medications and opioid analgesics are used cautiously in the client who is being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The client may exhibit anxiety during the weaning process for a variety of reasons; therefore, distractions such as radio, television, and visitors are still very useful.