Nokea
A client who was admitted for the treatment of thyroid storm (hyperthyroidism) is preparing for discharge. The client is anxious about the illness and is, at times, emotionally labile. Which intervention is most appropriate for the nurse to implement at this time?
- A. Assist the client with identifying coping skills, support systems, and potential stressors.
- B. Avoid teaching the client anything about the disease until he or she is emotionally stable.
- C. Reassure the client that everything will usually be fine after returning to one's home and family.
- D. Explain that being able to control of one's behavior must be achieved being discharge to home can occur.
Correct Answer: A
Rationale: It is normal for clients who experience thyroid storm (hyperthyroidism) to continue to be anxious and emotionally labile at the time of discharge. The best intervention is to help the client cope with these changes in behavior and to anticipate potential stressors so that symptoms will not be as severe. Options 2 and 3 block communication by either avoiding the issue or providing false reassurance. The confrontation described in option 4 will only heighten his anxiety.
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A 16-year-old client diagnosed with diabetes is admitted for hyperglycemia. The client states, 'I'm fed up with having my life ruled by diets, doctors' prescriptions, and machines!' Based on this assessment data, which is the priority client concern?
- A. A chronic illness
- B. A personal crisis
- C. Feelings of loss of control
- D. Lack of understanding about nutrition
Correct Answer: C
Rationale: Adolescents strive for identity and independence, and the situation describes a common fear of loss of control. Therefore, the priority problem relates to these feelings of loss of control. Although the child has a chronic illness and may be experiencing a personal crisis, the child's statement focuses on loss of control. There is no information in the question that indicates a lack of knowledge.
A community health nurse visits a recently widowed retired military client. When the nurse visits, the ordinarily immaculate house is in chaos, and the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement should the nurse make to the client?
- A. I can see this isn't a good time to visit.
- B. You seem to be having a very troubling time.
- C. Do you think your wife would want you to behave like this?
- D. What are you doing? How much are you drinking and for how long?
Correct Answer: B
Rationale: The therapeutic statement is the one that helps the client explore his situation and express his feelings. Reflection, by telling the client that the nurse feels that he is experiencing a troubled or difficult time, is empathic, and it will assist the client with beginning to ventilate his feelings. Option 1 uses humor to avoid therapeutic intimacy and effective problem-solving. Option 3 uses admonishment and tries to shame the client, which is not therapeutic or professional. This social communication belittles the client, will likely cause anger, and may evoke 'acting out' by the client. Option 4 uses social communication.
The nurse is seeing a client in the clinic with her 18-month-old daughter. The client asks the nurse when her child should start going to the dentist. Which response by the nurse is correct?
- A. She should go by her first birthday.
- B. She should start receiving oral exams at 2 years of age.
- C. She should go to a dentist once a year beginning at age 3.
- D. You don't need to worry about it until she starts kindergarten.
Correct Answer: A
Rationale: The American Academy of Pediatric Dentistry recommends a dental visit by the first birthday to establish a dental home and prevent early childhood caries.
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
- A. I can understand what you mean. I'd be nervous too if I were in your shoes.
- B. This surgery is so successful that I wouldn't be concerned at all if I were you.
- C. Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.
- D. Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens.
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.
Based on Maslow's hierarchy of needs, which client is demonstrating characteristics of self-actualization?
- A. Client is competent and esteemed by others for accomplishing work goals
- B. Client maintains a stable, loving, same-sex partnership for several years
- C. Client learns to sublimate aggressive impulses using physical exercises
- D. Client has an accurate perception of reality and is accepting of self and others
Correct Answer: D
Rationale: According to Maslow's hierarchy of needs, self-actualization is the highest level where individuals strive to reach their full potential and achieve personal growth. A self-actualized person, as per Maslow, has an accurate perception of reality and is accepting of themselves and others. This individual is characterized by traits such as fairness, independence, spontaneity, and creativity. While choices A, B, and C represent important aspects of human needs fulfillment, they align more closely with lower levels in Maslow's hierarchy. Choice A refers to meeting self-esteem needs, choice B relates to love and belonging needs, and choice C addresses safety needs, all of which are below self-actualization in the hierarchy of needs.