Nokea
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
- A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
- B. Notify the healthcare provider and request a prescription for a large-volume enema.
- C. Assess the client's medical record to determine the client's normal bowel pattern.
- D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
Correct Answer: C
Rationale: The first step in addressing a client's reported change in bowel habits is to assess the client's normal bowel pattern. This assessment helps the nurse understand the client's typical bowel habits and identify any deviations from the norm. By assessing the medical record first, the nurse gains valuable information that guides further interventions. In this scenario, offering prune juice (Option A) or increasing fluids (Option D) may not be appropriate until the client's normal bowel pattern is known. Notifying the healthcare provider for a large-volume enema (Option B) is premature without understanding the client's baseline. Therefore, assessing the client's medical record is the priority before proceeding with any interventions.
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The nurse is teaching a group of women at a community center about risk factors for spousal abuse. Which would the nurse identify as risk factors? Select all that apply.
- A. alcohol or drug use
- B. low income or poverty
- C. being over the age of 40
- D. a higher level of education
- E. having a large circle of friends
- F. pregnancy, especially if it is unplanned
Correct Answer: A,B,F
Rationale: Alcohol/drug use, poverty, and unplanned pregnancy are established risk factors for spousal abuse. Age, education, and social circles are not specific risk factors.
The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a 'tearing' sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the nurse make?
- A. Try not to worry, you and your baby are in good hands.'
- B. I understand your concerns. I'll let your health care provider know you need to talk.'
- C. I don't have time to answer questions now but I'll plan for us to have time to talk later.'
- D. I can understand that you are fearful. We are doing everything possible for your baby.'
Correct Answer: D
Rationale: Clients have a concern for the safety of their baby during labor and delivery, especially when a problem arises. Empathy and a calm attitude with realistic reassurances are important aspects of client care. Dismissing or ignoring the client's concerns can lead to increased fear and a lack of cooperation. Option 1 uses a cliché and provides false reassurance. Options 2 and 3 place the client's feelings on hold.
The nurse is developing a plan of care for a client scheduled for an above-the-knee leg amputation. Which action should the nurse include in the plan of care when addressing the psychosocial needs of the client?
- A. Explain to the client that open grieving is abnormal.
- B. Encourage the client to express feelings about body changes.
- C. Advise the client to seek psychological treatment after surgery.
- D. Discourage sharing with others who have had similar experiences.
Correct Answer: B
Rationale: Surgical incisions or the loss of a body part can alter a client's body image. The onset of problems coping with these changes may occur during the immediate or extended postoperative stage. Nursing interventions primarily involve providing psychological support. The nurse should encourage the client to express how he or she feels about these postoperative changes that will affect his or her life. Option 1 is an incorrect statement because open grieving is normal. Option 3 indicates disapproval, and in option 4, the nurse is giving advice.
Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
- A. My son came to visit me yesterday.
- B. At least I can speak and answer questions.
- C. I have a problem turning my neck to the side.
- D. Look at me, I can no longer be the head of my family.
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.