Nokea
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.
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The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
- A. Tell me what you think you did wrong.'
- B. Maybe we can keep your father in the hospital for a while longer to give you a rest.'
- C. You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care.'
- D. An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed.'
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
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.
The nurse is assessing a client to determine the client's adjustment to presbycusis. Which indicates successful adaptation by the client to this problem?
- A. Proper use of a hearing aid
- B. Denial of a hearing impairment
- C. Withdrawal from social activities
- D. Reluctance to answer the telephone
Correct Answer: A
Rationale: Presbycusis occurs as part of the aging process; it is a progressive sensorineural hearing loss. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Some clients may not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid.
The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.