Nokea
A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse should initially allow the client to continue this behavior because it has what therapeutic effect for the client?
- A. Relieves the client's anxiety
- B. Decreases the chance of infection
- C. Gives the client a feeling of self-control
- D. Increases the client's sense of self-esteem
Correct Answer: A
Rationale: The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Options 2 and 3 are also incorrect interpretations of the client's need to perform this behavior. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.
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The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
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.
A client has been diagnosed with terminal cancer and is using opioid analgesics for pain relief. Which action by the home care nurse would best allay the client's anxiety about becoming addicted to the pain medication?
- A. Encouraging the client to hold off as long as possible between doses of pain medication
- B. Encouraging the client to take lower doses of medications even though the pain is not well controlled
- C. Explaining to the client that the fears are justified but should be of no concern during the final stages of care
- D. Explaining to the client that addiction rarely occurs in individuals who are taking medication appropriately to relieve pain
Correct Answer: D
Rationale: Clients who are on opioid analgesics often have well-founded fears about addiction, even in the face of pain. The nurse has the responsibility to provide correct information about the likelihood of addiction while still maintaining adequate pain control. Addiction is rare for individuals who are taking medication to relieve pain. Allowing the client to be in pain, as in options 1 and 2, is not acceptable nursing practice. Option 3 is only partially correct in that it acknowledges the client's fear.
The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.
A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care?
- A. Attend a support group.
- B. Cease dwelling on the negative.
- C. Reach out for help to face this fear.
- D. Share her feelings with her partner.
Correct Answer: D
Rationale: Talking to the client about sharing her feelings with her husband directly addresses the subject of the question. Encouraging the client to start a support group will not address the client's immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client's concern.