Nokea
A client who is hospitalized with anorexia nervosa states during a one-to-one session with the nurse, 'I'm freaking out. I'm losing it.' Which nurse response would be most therapeutic at this time?
- A. Would you feel better if I called your parents?'
- B. Just sit here and relax and maintain control.'
- C. Let me sit with you for a while.'
- D. Tell me what thoughts are going through your head.'
Correct Answer: D
Rationale: The correct answer is D because it encourages the client to express their thoughts and feelings, aiding in the therapeutic process. This response promotes open communication and allows the nurse to assess the client's mental state. Choice A may not address the client's immediate distress and could potentially escalate anxiety. Choice B dismisses the client's feelings and does not address the issue. Choice C offers support but does not actively encourage the client to verbalize their thoughts, which is crucial in addressing underlying issues.
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For which behavior(s) would limit setting be most essential?
- A. A patient clings to the nurse and asks for advice about inconsequential matters.
- B. A woman is flirtatious and provocative toward staff members of the opposite sex.
- C. An elderly man displays hypervigilance and refuses to attend unit activities.
- D. A young woman urges a suspicious patient to hit anyone who stares at him.
Correct Answer: D
Rationale: The correct answer is D because it involves a behavior that is potentially harmful and puts others at risk. Setting limits is essential to prevent violence and protect both the patient and others. A: Clinging behavior is not inherently harmful. B: Flirtatious behavior, while inappropriate, does not pose a direct threat. C: Hypervigilance and refusal to attend activities may indicate underlying issues but do not require immediate limit setting for safety.
An infant develops jaundice 6 hours after birth. Which one of the following is the most likely diagnosis?
- A. Haemolytic disease of the newborn.
- B. Umbilical sepsis.
- C. Physiological jaundice.
- D. Atresia of the bile ducts.
Correct Answer: A
Rationale: Jaundice within 24 hours of birth is pathological, often due to haemolytic disease of the newborn (A), such as Rh incompatibility causing rapid red cell breakdown. Physiological jaundice (C) typically appears after 24 hours, while umbilical sepsis (B), bile duct atresia (D), and neonatal hepatitis (E) are less likely to cause such early onset.
A depressed patient who is taking a tricyclic antidepressant tells the nurse, "I don't think I can keep taking these pills. They make me very dizzy, especially when I stand up." The best nursing response is:
- A. That is annoying, but it is something most patients are able to learn to live with as time goes on. You'll get used to the medicine's side effects.
- B. The medicine can slow the body's adjustment of blood pressure when changing position; drinking more fluids and changing position slowly can help.
- C. Compared to the problems caused by the depression, it seems like a relatively small annoyance to have to put up with.
- D. All medicines have side effects, and this one is relatively mild. It could be that your depression is causing you to think negatively about the medicine.
Correct Answer: B
Rationale: The correct answer is B because tricyclic antidepressants can cause orthostatic hypotension leading to dizziness upon standing. Advising the patient to drink more fluids and change positions slowly can help alleviate this symptom. Choice A minimizes the patient's concern, which is not therapeutic. Choice C diminishes the patient's experience and feelings. Choice D dismisses the patient's symptoms and attributes them solely to the patient's negative thinking, which is not appropriate.
A nurse works a rape telephone hotline. Communication should focus on:
- A. Explaining immediate steps victims should take;
- B. Providing callers with a sympathetic listener.
- C. Obtaining information for law enforcement.
- D. Arranging long-term counseling.
Correct Answer: A
Rationale: The correct answer is A because in cases of sexual assault, immediate steps such as seeking medical attention, preserving evidence, and contacting authorities are crucial. Providing sympathy (B) is important but secondary to ensuring victims' safety. Obtaining information for law enforcement (C) should only be done if victims consent, as their safety and well-being are the priority. Long-term counseling (D) is important but not the immediate focus on a hotline call.
The nurse is administering haloperidol (Haldol) to a client experiencing delusions and hallucinations associated with schizophrenia. The nurse can expect symptom abatement as a result of the drug's action to:
- A. Reduce the number of brain cells that crave dopamine
- B. Block dopamine receptors, making dopamine less available
- C. Enhance dopamine receptors, making more dopamine available
- D. Cause increased cellular production of dopamine
Correct Answer: B
Rationale: The correct answer is B because haloperidol is a typical antipsychotic that works by blocking dopamine receptors in the brain. By blocking these receptors, haloperidol reduces the effects of excess dopamine, which is known to contribute to symptoms of schizophrenia such as delusions and hallucinations. This action helps alleviate the positive symptoms of schizophrenia.
Choice A is incorrect because haloperidol does not reduce the number of brain cells that crave dopamine; it acts on the receptors themselves. Choice C is incorrect because enhancing dopamine receptors would lead to an increase in the effects of dopamine, worsening symptoms. Choice D is incorrect because haloperidol does not cause increased cellular production of dopamine; it blocks dopamine receptors instead.