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A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial about his medical condition?
- A. Requests a sedative for sleep at 10:00 pm
- B. Expresses a hesitancy to leave the hospital
- C. Consumes 25% of foods and fluids given for supper
- D. Walks up and down three flights of stairs unsupervised
Correct Answer: D
Rationale: Ignoring activity limitations and avoiding lifestyle changes are signs of the denial stage. Walking three flights of stairs should be a supervised activity during this phase of the recovery process. Option 1 is an appropriate client action on the evening before discharge. Option 2 may be a manifestation of anxiety or fear rather than denial. Option 3 is a manifestation of depression rather than denial.
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The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which statement is best for the nurse to make to the parents at this time?
- A. You should focus on your baby's personality, not appearance.
- B. Let me show you pictures of some babies before and after surgery.
- C. There are other problems with this condition that go beyond surgical correction.
- D. Has anyone else in either of your families had cleft lip or palate?
Correct Answer: B
Rationale: Showing pictures of successful surgical outcomes provides hope and tangible evidence of improvement, addressing the parents’ grief and concerns about appearance. Other options may dismiss emotions, overwhelm with additional concerns, or be irrelevant at this stage.
The nurse is performing a neurological assessment on a client with a diagnosis of dementia and assessing the function of the frontal lobe of the brain. Which should the nurse assess to yield the best information about this area of functioning?
- A. Eye movements
- B. Feelings or emotions
- C. Level of consciousness
- D. Insight, judgment, and planning
Correct Answer: D
Rationale: Insight, judgment, and planning are part of the function of the frontal lobe. Eye movements are under the control of cranial nerves III, IV, and VI. Feelings and emotions are part of the role of the limbic system. The level of consciousness is controlled by the reticular activating system.
A charge nurse is supervising a new nurse who is providing care to a client diagnosed with end-stage heart failure. The client is withdrawn and reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement, if made by the new nurse to the client, indicates that the new nurse has a need for further teaching regarding the use of therapeutic communication techniques?
- A. What are your feelings right now?'
- B. Why don't you feel like getting up for your bath?'
- C. These dreams you mentioned, what are they like?'
- D. Many clients with end-stage heart failure fear death.'
Correct Answer: B
Rationale: When the nurse asks a 'why' question of the client, the nurse is requesting an explanation for feelings and behaviors when the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the nurse is encouraging the verbalization of emotions or feelings, which is a therapeutic communication technique. In option 3, the nurse is using the therapeutic communication technique of exploring, which involves asking the client to describe something in more detail or to discuss it more fully. In option 4, the nurse is using the therapeutic communication technique of giving information. Identifying the common fear of death among clients with end-stage heart failure may encourage the client to voice concerns.
The nurse is caring for a client with end-stage kidney disease and multiple organ failure. Which action by the nurse indicates an understanding of end-of-life care? Select all that apply.
- A. The nurse explains signs and symptoms that indicate death is near.
- B. The nurse explains to the client and family what to expect during the final phase of the illness.
- C. Cultural beliefs are acknowledged, but priority is placed on life-lengthening treatment options.
- D. The nurse avoids talking to the client about impending death to avoid upsetting him and the family.
- E. The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation.
Correct Answer: A,B,E
Rationale: Explaining signs of nearing death (A), what to expect (B), and discussing goals/wishes (E) support informed, compassionate end-of-life care. Prioritizing life-lengthening treatments (C) disregards palliative focus, and avoiding death discussions (D) hinders open communication.
A hospitalized client has participated in substance abuse therapy group sessions. Which statement by the client would best indicate that the client has assimilated session topics, understood coping response styles, and processed information effectively for self-use?
- A. I'll keep all my appointments, and I'll do everything I'm supposed to. That way nothing will go wrong.'
- B. I know I'm ready to be discharged. I feel like I'll have no problem saying no and leaving a group of friends if they are drinking.'
- C. This group has really helped a lot. I know that it will be different when I go home. But I'm sure that my family and friends will all help me, like the people in this group have. They'll all help me, I know they will. They won't let me go back to old ways.'
- D. I'm looking forward to leaving here, but I know that I will miss all of you. So, I'm happy, and I'm sad. I'm excited, and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you all have been. I know it isn't going to be easy, but I'm going to try as hard as I can.'
Correct Answer: D
Rationale: In option 4 the client is expressing real concern and ambivalence about discharge from the hospital. The client demonstrates an ability to perceive reality in the appraisal regarding the lifestyle changes that will have to be initiated, as well as the fact that the client will have to work hard and develop new friends and meeting places. With the defense mechanism of denial, the person denies reality. There can be varying degrees of this denial. In option 1 the client is concrete and procedure oriented; again, the client verbalizes denial. Option 2 identifies denial. In option 3 the client is relying heavily on others, and the client's locus of control is external.