Nokea
A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client's concerns?
- A. I can show you how to gently stroke the face and not cause pain.
- B. It is a normal finding in large babies and nothing to be concerned about.
- C. The bruising is caused by polycythemia, which usually leads to jaundice.
- D. Because the bruising is painful, it is advisable that you not touch the baby's face.
Correct Answer: A
Rationale: The mother of an LGA infant with facial bruising may be reluctant to interact with the infant because of concern about causing additional pain to the infant. Touching the infant gently with the fingertips should be encouraged. The bruising is temporary. Option 2 does not address the mother's verbalized concerns. The LGA infant may have polycythemia, which can contribute to bruising, but the bruising is not actually caused by the polycythemia. Option 4 advises the mother not to touch the baby's face because the bruising is painful, but touch is an important component of the attachment process.
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A client diagnosed with catatonic schizophrenia demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. Which intervention by the nurse is most appropriate to increase interpersonal communication?
- A. Ask the client direct questions to encourage talking.
- B. Leave the client alone and intermittently check on her or him.
- C. Sit beside the client in silence and occasionally ask open-ended questions.
- D. Take the client into the dayroom with the other clients, to encourage interaction.
Correct Answer: C
Rationale: Clients who are withdrawn may be immobile and mute, and they require consistent, repeated approaches. Intervention includes the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. Asking this client direct questions is not therapeutic. The client is not to be left alone. This client is not capable of interaction in the dayroom.
A client is admitted to the psychiatric unit with a diagnosis of schizophrenia. The client verbalizes to the nurse, 'Someone wants to kill me tonight.' Which response by the nurse is best?
- A. No one wants to kill you.
- B. Why do you think that?
- C. They don't know you are hospitalized, so you are safe.
- D. It must feel frightening to think someone wants to hurt you.
Correct Answer: D
Rationale: Acknowledging the client’s fear validates their emotions and builds trust without reinforcing delusions. Denying the belief, questioning, or reassuring about safety may escalate agitation or distrust in a client with schizophrenia.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
A client experiencing urticaria (hives) and pruritus states to the nurse, 'What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy.' Which statement made by the nurse is the most therapeutic?
- A. You're troubled that this will extend into your wedding?
- B. It's probably just due to prewedding jitters. You'll be fine.
- C. The antihistamine will help a great deal, just you wait and see.
- D. Do you think this would really be something that could ruin your wedding?
Correct Answer: A
Rationale: The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety and fears. In option 3, the nurse talks about antihistamines and asks the client to 'wait and see.' This is nontherapeutic because the nurse is making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4, the nurse responds without sensitivity.
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.