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A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, 'Am I going to die?' Which response would the nurse make?
- A. Most individuals with your disease live a normal life span.
- B. Is your family here? I would like to explain your disease to all of you.
- C. The prognosis varies, as most individuals have remissions and exacerbations.
- D. Why don't you speak with your health care provider to get more details?
Correct Answer: C
Rationale: The most appropriate response to the client's question regarding their prognosis is to acknowledge the variable nature of multiple sclerosis by stating that 'The prognosis varies, as most individuals have remissions and exacerbations.' This response provides realistic information while offering some hope. Choice A ('Most individuals with your disease live a normal life span.') gives false reassurance as repeated exacerbations may affect life span. Choice B ('Is your family here? I would like to explain your disease to all of you.') does not directly address the client's question and involves the family unnecessarily. Choice D ('Why don't you speak with your health care provider to get more details?') deflects the responsibility and does not address the client's immediate concerns about their prognosis.
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A 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. A few hours later the mother tells the nurse, 'I have to leave now, but whenever I try to go, my child gets upset, and then I start to cry.' Which is the best action by the nurse?
- A. Walking the mother to the elevator
- B. Encouraging the mother to spend the night
- C. Staying with the child while the mother leaves
- D. Telling the mother to wait until the child falls asleep
Correct Answer: C
Rationale: The best action for the nurse in this situation is to stay with the child while the mother leaves. By doing so, the nurse can provide comfort and reassurance to both the child and the mother. This approach acknowledges the mother's need to leave while ensuring the child is not left alone and is supported during the separation. Walking the mother to the elevator does not address the child's emotional needs and may not provide adequate support. Encouraging the mother to spend the night is not necessary and may not be feasible for her. Telling the mother to wait until the child falls asleep is not recommended as it may create a sense of dishonesty and uncertainty for the child, who should be aware of the mother's departure and reassured that she will return.
Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?
- A. Ask whether the voices are male or female and how many there are.
- B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
- C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
- D. Encourage the client to leave the room and keep busy to distract from the voices.
Correct Answer: B
Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.
Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?
- A. Ask whether the voices are male or female and how many there are.
- B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
- C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
- D. Encourage the client to leave the room and keep busy to distract from the voices.
Correct Answer: B
Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.
A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?
- A. Tell me more about your concerns.''
- B. Products are available to address this issue.''
- C. This is a valid concern, and we can discuss ways to manage it.''
- D. Many individuals who undergo this procedure have similar worries.''
Correct Answer: A
Rationale: The response ''Tell me more about your concerns'' is open-ended, encouraging the client to express their worries freely. This approach fosters communication and shows empathy. Option B acknowledges the concern and offers a solution, demonstrating support and understanding. Option C validates the client's worry and suggests collaboration in finding solutions. Option D normalizes the concern but may not address the client's specific worries, making it less therapeutic than the other options. Overall, actively listening to the client's concerns and offering support are essential in providing holistic care.
An adolescent reports irregularity in menses. Her mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image. Which could be the reason for irregular menses?
- A. Bulimia
- B. Anorexia
- C. Orthorexia
- D. Binge eating disorder
Correct Answer: B
Rationale: The correct answer is 'Anorexia.' Anorexia is characterized by a lack of caloric intake motivated by a strong fear of gaining weight, leading to poor nutrition and potential irregular menses. Bulimia involves binge eating followed by compensatory behaviors. Orthorexia is characterized by an obsession with eating only healthy or 'pure' foods. Binge eating disorder is characterized by consuming large amounts of high-calorie food in a short period.