Nokea
A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?
- A. Guilt
- B. Grief
- C. Anger
- D. Depression
Correct Answer: B
Rationale: The nurse should recognize that a mother will go through the grief process after giving birth to a child with a birth defect. After the grief process, the mother can begin to focus on bonding with the infant. The remaining options are incorrect because they are each only one component of the grief process.
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The nurse provides care for a client diagnosed with dementia. The nurse instructs the unlicensed assistive personnel (UAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)
- A. Sing or talk to the client throughout the activity.
- B. Expose only one area at a time while bathing.
- C. Complete the bath as quickly as possible.
- D. Organize all supplies before starting the bath.
- E. Bathe the client slowly and explain each action.
Correct Answer: A,B,D,E
Rationale: For a client with dementia, appropriate bathing strategies include: (A) Singing or talking to provide comfort and reduce anxiety; (B) Exposing only one area to maintain dignity and prevent chilling; (D) Organizing supplies to minimize disruption; (E) Bathing slowly and explaining actions to reduce confusion. Completing the bath quickly (C) may increase agitation and is not appropriate.
A client with schizophrenia states to the nurse, 'I am a spy for the FBI. I am an eye, an eye in the sky.' Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
- A. Echolalia
- B. Word salad
- C. Clang associations
- D. Loosened associations
Correct Answer: C
Rationale: The repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern seen in clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another. Loosened associations occur when the individual speaks with frequent changes of subject and when the content is only obliquely related.
While assisting with bathing, the client who has sustained a spinal cord injury states, 'I can't do this. I wish I were dead.' Which therapeutic response should the nurse make to encourage communication?
- A. Why do you say that?
- B. You wish you were dead?
- C. Would you prefer a shower instead?
- D. Are you frustrated with your limitations?
Correct Answer: B
Rationale: Clarifying is a therapeutic technique that involves restating what was said to obtain additional information. By asking 'why' in option 1, the nurse puts the client on the defensive. Option 3 changes the subject. In option 4, false reassurance is offered. The remaining options are nontherapeutic statements that block communication.
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?
- A. Ask a family member to stay with the client during the procedure.
- B. Give the client the call bell, and encourage its use if the client feels worse.
- C. Leave the client alone only to gather the required equipment and medications.
- D. Stay with the client, and ask another nurse to gather needed equipment and supplies.
Correct Answer: D
Rationale: The client with pulmonary edema is experiencing severe anxiety, which can exacerbate the condition and hinder treatment. Staying with the client provides emotional support and reassurance, addressing the psychosocial aspect of care, while delegating equipment gathering ensures efficient preparation for treatment. This holistic approach meets both the emotional and physical needs of the client. Option 1 may not be feasible or sufficient to address immediate anxiety. Option 2 does not provide active support, and option 3 leaves the client alone, which could increase anxiety.
The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, 'Get it yourself!' The nurse recognizes the charge nurse is displaying which defense mechanism?
- A. Compensation.
- B. Displacement.
- C. Conversion.
- D. Projection.
Correct Answer: B
Rationale: Displacement involves redirecting emotions from one target to another. The charge nurse, upset from the reprimand, displaces anger onto the client by responding harshly to a simple request, rather than addressing the supervisor.