Nokea
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.
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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 recovering from a brain attack (stroke) has become irritable and angry regarding self-limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable?
- A. Ignore the behavior, knowing that the client is grieving.
- B. Allow longer and more frequent visitation by the spouse.
- C. Use supportive statements to correct the client's behavior.
- D. Stress that the nurses are experienced and know how the client feels.
Correct Answer: C
Rationale: Clients who have experienced a stroke have many and varied needs. It is also important to support and praise the client for accomplishments. The client may need her or his behavior pointed out so that correction can take place, and the client's behavior should not be ignored. Spouses of a stroke client are often grieving; therefore, more visitations may not be helpful. Additionally, short visits are often encouraged. Stating that the nurse knows how the client feels is inappropriate.
The nurse provides care for a client diagnosed with paranoid schizophrenia. The client’s spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?
- A. Assign the client to straighten up the day room.
- B. Establish a trusting nurse-client relationship.
- C. Encourage the client to sleep and offer a sleep aid.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Encouraging sleep and offering a sleep aid addresses the client’s insomnia, which can exacerbate paranoia and schizophrenia symptoms. A trusting relationship is important but less urgent, and other options do not address the immediate need for rest.
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.
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.