Nokea
A client with superficial varicose veins states to the nurse, 'I hate these things. They're so ugly. I wish I could get them to go away.' Which therapeutic response would be most appropriate for the nurse to make to the client?
- A. You should try sclerotherapy. It's great.
- B. What makes you so upset about having ugly varicose veins?
- C. What have you been educated about varicose veins and their management?
- D. I understand how you feel, but you know, they really don't look all that bad.
Correct Answer: C
Rationale: The client expressing distress about physical appearance has a risk for an altered body image. The nurse assesses the client's knowledge and self-management of the condition as a means of empowering the client and helping him or her adapt to the body change. Options 1 and 4 are not therapeutic. Option 2 focuses only on the cosmetic aspect of varicose veins.
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The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?
- A. Amoxicillin is an antibiotic that will help you get well.
- B. This medicine tastes just like fresh strawberries.
- C. You can't drink anything for an hour after taking this medicine.
- D. If you don't want to drink this medicine, I can give you a shot instead.
Correct Answer: A
Rationale: Informing the client that amoxicillin is an antibiotic that will help them recover provides age-appropriate education about the medication’s purpose, promoting understanding and adherence. Other options may mislead or unnecessarily alarm the child.
Which initial response would the nurse make to a 67-year-old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have an erection for several years?
- A. At your age, sex isn't that important.''
- B. That is a natural occurrence at your age.''
- C. You sound upset about not being able to have an erection.''
- D. Maybe it's time for you to speak to your primary health care provider about this.''
Correct Answer: C
Rationale: The correct response is, 'You sound upset about not being able to have an erection.' When a client discloses personal information, the nurse should respond in a non-judgmental manner to encourage further communication and gather more details. This response demonstrates empathy and understanding, opening the door for the patient to express his feelings and concerns. Choice A, 'At your age, sex isn't that important,' is dismissive and fails to address the client's emotions or concerns, potentially hindering open communication. Choice B, 'That is a natural occurrence at your age,' provides inaccurate information as the inability to have an erection is not considered a normal part of aging. Choice D, 'Maybe it's time for you to speak to your primary health care provider about this,' while important eventually, should not be the initial response as the nurse should first explore the client's feelings and concerns before discussing potential referrals or interventions.
A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?
- A. An attempt to punish the nursing staff
- B. A constructive method of accepting reality
- C. A defense against underlying depression and fear
- D. An effort to maintain life and to live it as fully as possible
Correct Answer: C
Rationale: The client's angry, critical communication and non-adherence to treatment suggest underlying emotional struggles. The behavior is likely a defense mechanism against feelings of depression and fear. It is essential to consider that the client's actions are not intentionally aimed at punishing others but rather a manifestation of internal distress. Option A is incorrect as the behavior is not about punishing the nursing staff. Option B is incorrect because the behavior is not a constructive way of accepting reality but rather a maladaptive coping mechanism. Option D is incorrect as the behavior is not primarily driven by an effort to maintain life but rather by emotional distress.
What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?
- A. Feelings of guilt
- B. Need to control others
- C. Desire for punishment
- D. Excessive physical activity
Correct Answer: D
Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.
A charge nurse is supervising a new nurse who is providing care to a client diagnosed with end-stage heart failure. The client is withdrawn and reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement, if made by the new nurse to the client, indicates that the new nurse has a need for further teaching regarding the use of therapeutic communication techniques?
- A. What are your feelings right now?'
- B. Why don't you feel like getting up for your bath?'
- C. These dreams you mentioned, what are they like?'
- D. Many clients with end-stage heart failure fear death.'
Correct Answer: B
Rationale: When the nurse asks a 'why' question of the client, the nurse is requesting an explanation for feelings and behaviors when the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the nurse is encouraging the verbalization of emotions or feelings, which is a therapeutic communication technique. In option 3, the nurse is using the therapeutic communication technique of exploring, which involves asking the client to describe something in more detail or to discuss it more fully. In option 4, the nurse is using the therapeutic communication technique of giving information. Identifying the common fear of death among clients with end-stage heart failure may encourage the client to voice concerns.