Nokea
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. a panic attack.
Correct Answer: C
Rationale: In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced. Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act.
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An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. Inform the client that because she is underage, she is at fault for attending a party where alcohol was served
- B. Ask the client if anyone witnessed the event because the client was intoxicated and might not remember correctly
- C. Inform the client that it was not her fault, and support the client through the physical examination
- D. Question whether the woman had consensual sex and now just feels guilty
Correct Answer: C
Rationale: Supporting the client and affirming that the rape was not her fault is critical, as acquaintance rape is serious and not negated by alcohol consumption.
The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse's next action should be to:
- A. do nothing; the client has the right to refuse treatment.
- B. report the incident to the police.
- C. arrange an appointment with the client's next of kin.
- D. educate the client about available services.
Correct Answer: D
Rationale: Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services. Frequently elders are not aware of existing programs.
A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
- A. I am having difficulty paying for this new antibiotic the physician prescribed.
- B. I am a little short on cash since my daughter moved in to help me.
- C. I have not felt like shopping since the weather has gotten worse.
- D. People do not realize how difficult it is to make ends meet on a fixed income.
Correct Answer: B
Rationale: Signs of financial abuse include an inability to pay for necessities like clothes, and the statement about being short on cash since the daughter moved in suggests possible misuse of funds by a caregiver.
After the client discusses her relationship with her father, the nurse says, 'Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?' This is an example of:
- A. verbalizing the implied.
- B. seeking consensual validation.
- C. encouraging evaluation.
- D. suggesting collaboration.
Correct Answer: B
Rationale: Consensual validation is a technique used to check one's understanding of what the client has said. Consensual validation is the process by which people come to agreement about the meaning and significance of specific symbols. Through this experience, individuals develop the ability to relate effectively.
Which of the following diseases places a client at risk for developing cirrhosis?
- A. type I diabetes
- B. alcoholism
- C. leukemia
- D. glaucoma
Correct Answer: B
Rationale: Alcoholism places a client at risk for developing cirrhosis. None of the other choices are related to cirrhosis.