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.
You may also like to solve these questions
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
- A. Tell me more specifically about her complaints.
- B. Can you think why she might nag you so much?
- C. I'll help you think about how to bring this up yourself tomorrow afternoon.
- D. Why do you want me to initiate this in tomorrow's session rather than you?
Correct Answer: C
Rationale: The client needs to learn how to communicate directly with his wife about her behavior. The nurse's assistance enables him to practice a new skill and communicates confidence in his ability to confront this situation. Choices 1 and 2 inappropriately direct attention away from the client and toward his wife, who isn't present. Choice 4 implies that there might be a legitimate reason for the nurse to assume responsibility for something that rightfully belongs to the client. Instead of focusing on his problems, he'll waste precious time convincing the nurse that he or she should do his work.
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.
Nurses should understand the chain of infection because it refers to:
- A. the linkages between various forms of microorganisms.
- B. the sequence required for transmission of disease.
- C. the clustering of bacteria in a specific pattern.
- D. increasing virulence patterns among species of microorganisms.
Correct Answer: B
Rationale: Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, and entry into a susceptible host.
During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:
- A. inquire about foods the child is eating.
- B. ask about the possibility of sexual abuse.
- C. request to see the type of bottle used for feedings.
- D. question the parent about objects the child plays with.
Correct Answer: B
Rationale: Generally oral sex leaves little physical evidence. Injury to the soft palate (such as bruising, abrasions, and petechiae) and pharyngeal gonorrhea are the only signs. Infants are at risk for sexual abuse.
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.