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A client is assessed by the nurse as experiencing a crisis. The nurse plans to:
- A. allow the client to work through independent problem-solving.
- B. complete an in-depth evaluation of stressors and responses to the situation.
- C. focus on immediate stress reduction.
- D. recommend ongoing therapy.
Correct Answer: C
Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning.
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A 24 year-old man has been admitted to the hospital due to work-related back injury. The patient's wife would like to see the patient's chart. The nurse should:
- A. Provide the chart to the patient's wife following verbal approval by the patient.
- B. Provide the chart to the patient's wife after consulting with the patient's physician.
- C. Get written approval from the patient prior to providing the wife with chart information and call the MD about the patient's request.
- D. Tell the patient's wife, a copy of the patient's medical record is on-file with medical records.
Correct Answer: C
Rationale: Some facilities require the physician to be notified about a patient's request and written permission from the husband is required for the wife to view the chart.
James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial.
- B. suppression.
- C. displacement.
- D. fantasy.
Correct Answer: C
Rationale: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object.
A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
- A. fluid volume excess.
- B. hyperkalemia.
- C. hypercalcemia.
- D. fluid volume deficit.
Correct Answer: D
Rationale: For a client with an elevated urine osmolarity, the nurse should assess the client for fluid volume deficit.
What is the reason for a contract between nurse and client?
- A. Contracts state the roles the participants take.
- B. Contracts are indicative of the feeling tone established between participants.
- C. Contracts are binding and prevent either party from ending the relationship prematurely.
- D. Contracts spell out the participation and responsibilities of both parties.
Correct Answer: D
Rationale: A contract emphasizes that the nurse works with the client, rather than doing something for the client. Working with suggests that each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, nor is premature termination expressly forbidden.
A nurse is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
- A. Horizontal
- B. Sagittal
- C. Frontal
- D. Vertical
Correct Answer: B
Rationale: Sagittal motion occurs in the midline plane of the body.