Nokea
A client wanders in and out of other clients' rooms, taking their possessions while singing to himself and then giggling for no apparent reason. The nurse reacts therapeutically by taking which action?
- A. Putting arms around the client, saying, 'You're okay. You just need a hug.'
- B. Saying, 'I can see you are very anxious today. Let's go and play the piano.'
- C. Taking the client to the seclusion room until he cooperates with unit rules.
- D. Taking the client to the lounge and saying, 'Sit here and try to behave yourself.'
Correct Answer: B
Rationale: The use of a defense mechanism allows a person to avoid the painful experience of anxiety or transform it into a more tolerable symptom, such as regression. Regression allows the threatened client to move backward developmentally to a stage in which more security is felt. The recognition of regression is a signal that the client feels anxious. The correct option will help the client feel less anxious. A hug does not address the client's anxiety. The remaining options are restrictive and degrading.
You may also like to solve these questions
A client has a cerclage placed at 16 weeks' gestation. She has had no contractions and her cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?
- A. I will need more frequent prenatal visits.'
- B. I should call if I am leaking fluid or have bleeding or contractions.'
- C. I can have sex again in about 2 weeks.'
- D. I can have nothing in my vagina until I am at term.'
Correct Answer: C
Rationale: Sexual intercourse is typically contraindicated after cerclage until term to prevent complications. The other statements reflect correct understanding of cerclage care.
The nurse is obtaining a nursing history of a client suspected of having hepatitis C. The nurse should ask the client if he has:
- A. Drunk contaminated water.
- B. Traveled to India.
- C. Had a tattoo.
- D. Eaten shellfish.
Correct Answer: C
Rationale: Hepatitis C is commonly transmitted through blood exposure, such as via tattoos with unsterile equipment. The other options are more associated with hepatitis A.
A 5-year-old child is admitted with a fever and rash. The nurse suspects scarlet fever. Which assessment finding supports this diagnosis?
- A. Strawberry tongue
- B. Koplik spots
- C. Vesicular rash
- D. Pustules on the trunk
Correct Answer: A
Rationale: Strawberry tongue is a characteristic sign of scarlet fever, caused by group A Streptococcus, aiding in diagnosis confirmation.
The nurse tells a rape victim that even if she was protected against pregnancy by a contraceptive and the attention of taking any legal action against her assailant, she should still be checked by a physician for early detection of which of the following?
- A. Sexually transmitted disease.
- B. Anxiety reaction.
- C. Periurethral tears.
- D. Menstrual difficulties.
Correct Answer: A
Rationale: A physician should check for sexually transmitted diseases, as rape increases the risk of infection, which requires early detection and treatment.
An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply.
- A. Friends can visit whenever they want.
- B. The scar will be small.
- C. The teen will be back in school in 1 week.
- D. Antibiotics will be given to prevent an infection.
- E. A dressing will stay in place for 1 week.
Correct Answer: B,C,D
Rationale: A small scar, school return in about a week, and prophylactic antibiotics are accurate expectations for appendectomy recovery. Unrestricted visits and prolonged dressing use are incorrect.