Nokea
A client is suspected of having posttraumatic stress disorder. Which problem is the most important for the nurse to assess?
- A. panic attacks
- B. anorexia
- C. suicide
- D. short-term memory loss
Correct Answer: C
Rationale: Suicide risk is the most critical to assess in PTSD due to high rates of suicidal ideation and attempts.
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A client who is in halo traction states to the visiting nurse, 'I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is.' Which therapeutic response should the nurse make to the client?
- A. If I were you, I would have had the surgery rather than suffer like this.
- B. No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously.
- C. Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around.
- D. Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think?
Correct Answer: C
Rationale: In option 3, the nurse employs empathy and reflection. The nurse then offers a strategy for problem-solving, which helps increase the peripheral vision of the client in halo traction. In option 1, the nurse undermines the client's faith in the medical treatment being employed by giving advice that is insensitive and unprofessional. In option 2, the nurse provides a social response that contains emotionally charged language that could increase the client's anxiety. In option 4, the nurse uses excessive questioning and gives advice, which is nontherapeutic.
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 pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
- A. Injury to the fetus because of maternal distress
- B. Low self-esteem because of pregnancy complications
- C. Lack of understanding about diabetic self-care during pregnancy
- D. Poorly perceived body image caused by complications of pregnancy
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.
A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.