Nokea
A client is discussing his personal feelings of self-esteem and self-concept with a nurse. Which of the following questions is most appropriate for assessing the client's personal identity?
- A. What is your educational background?
- B. Are your parents still living?
- C. What do you like about your life right now?
- D. Where do you see yourself in 10 years?
Correct Answer: C
Rationale: When assessing a client's personal identity, it is essential for the nurse to inquire about aspects related to the client's self-perception and self-worth. Asking about what the client likes about his current life helps to explore his positive self-perceptions and areas of contentment. This question encourages the client to reflect on his present circumstances and identify aspects that contribute to his sense of personal identity. Choices A, B, and D are not as relevant for assessing personal identity as they focus on educational background, parental status, and future aspirations, respectively, rather than directly addressing the client's current self-perception and identity.
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When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct Answer: C
Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct Answer: D
Rationale: The nurse should monitor the client's serum sodium levels carefully when they have been on nasogastric (NG) tube suction for an extended period. Prolonged NG suctioning can lead to fluid loss and subsequent hyponatremia. Monitoring sodium levels is crucial to prevent complications. White blood cell count (Option A), albumin (Option B), and calcium (Option C) are not typically affected by prolonged NG suctioning. Therefore, these values are not the priority for monitoring in this situation.
A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?
- A. Just wait here and I will notify security.
- B. I'm going to speak with the physician about getting some medication that may help you.
- C. Why is your roommate trying to kill you?
- D. Have you called the police to report this?
Correct Answer: C
Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.
Which of the following is an age-related developmental task for a 68-year-old client?
- A. Dealing with loss of friends
- B. Commitment to parenthood
- C. Setting career goals
- D. Solidification of sense of self
Correct Answer: A
Rationale: As individuals age, they face various developmental tasks unique to that stage of life. For a 68-year-old client, dealing with the loss of friends becomes a significant aspect of their development. This age group often experiences the passing of peers and friends, leading to feelings of loneliness and the need to adjust to a changing social circle. Commitment to parenthood (Choice B) is more relevant to younger adults in their child-rearing years. Setting career goals (Choice C) is typically associated with early to mid-career stages rather than later in life. Solidification of sense of self (Choice D) is a task that is more commonly associated with earlier adulthood when individuals are establishing their identity. Therefore, the most appropriate developmental task for a 68-year-old client is dealing with the loss of friends.
Which of the following is an advantage of working with psychiatric clients in a group setting?
- A. Clients assist each other through therapeutic interventions with the support of a nurse
- B. Clients can receive peer support and feedback in a safe and controlled environment
- C. Clients can share experiences and coping strategies while maintaining confidentiality
- D. Clients learn from others when their behaviors are inappropriate in a safe and trusting environment
Correct Answer: D
Rationale: Group therapy is a valuable approach in mental health treatment. Working with psychiatric clients in a group setting offers various benefits. Clients in a group setting can learn from others when their behaviors are inappropriate in a safe and trusting environment. This environment allows individuals to express thoughts and feelings without fear of judgment or criticism, fostering a supportive atmosphere. Through interactions with peers, clients can gain insight into their own behaviors and learn alternative ways of coping. Choice A is incorrect as the presence and support of a nurse are typically important in group therapy sessions. Choice B is incorrect as group settings provide structure and rules to ensure a safe space for clients to express themselves. Choice C is incorrect as maintaining confidentiality is crucial in group therapy to build trust and encourage open sharing.