Nokea
A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: Of the nursing diagnoses listed, the client's statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent's role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.
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A 14 year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse first response be?
- A. Create an atmosphere of seclusion for the boy according to procedures.
- B. Remove other patients from the area via wheelchairs for added speed.
- C. Ask the patient, 'What is making you mad?'
- D. Ask the patient, 'Why are you doing this, have you thought about what your parents might say?'
Correct Answer: A
Rationale: Seclusion is your best option in this scenario to ensure safety and de-escalation.
Which of the following is not true of clinical pathways?
- A. They need to be updated daily.
- B. They show how the client is expected to respond to their diagnosis.
- C. The goal is improvement or discharge from the facility.
- D. They are evidence based.
Correct Answer: A
Rationale: Clinical pathways may be daily or weekly, so they may not need to be updated every day.
Activities of effective supervisors can be task-related or people-related activities. An example of a task-related supervisory activity is:
- A. Coaching
- B. Evaluating
- C. Delegating
- D. Facilitating
Correct Answer: C
Rationale: Delegating is a task-related supervisory activity, assigning work to competent staff, unlike the people-related activities of coaching, evaluating, or facilitating.
The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
- A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
- B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
- C. request that the family have a seat in the station rather than stand while awaiting its loved one.
- D. request that the family wait for its loved one in the Emergency Department waiting room.
Correct Answer: A
Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room, and the report should be resumed only after it can no longer hear what is said.
Which of the following nursing actions is most effective when evaluating a kinetic family drawing?
- A. telling the child to draw their family doing something
- B. offering specific suggestions of what to include in the drawing
- C. discouraging the child from talking about the drawing
- D. noting the omission of any family members
Correct Answer: D
Rationale: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the client to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.