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A client with the diagnosis of mania is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in the plan of care before seclusion?
- A. Ask the client if she understands why the seclusion is necessary.
- B. Remain silent because verbal interaction would be too stimulating.
- C. Tell the client that she will be allowed to come out when she can behave.
- D. Inform the client that she is being secluded to help regain her self-control.
Correct Answer: D
Rationale: Seclusion is a process in which a client is placed alone in a specially designed room for protection and close supervision. This client is removed to a nonstimulating environment as a result of her behavior. Options 1, 2, and 3 are nontherapeutic actions. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.
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Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
- A. Dissociation.
- B. Regression.
- C. Projection.
- D. Denial.
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.
The nurse is leading a crisis intervention group comprising high school students who have experienced the recent death of a classmate who committed suicide. The students are experiencing disbelief as they review the details of the suicide. Which should be the initial therapeutic action by the nurse?
- A. Ask how the students recovered from a death event in the past.
- B. Reinforce the students' ability to work through this death event.
- C. Inquire about the students' perception of their classmate's suicide.
- D. Reinforce the students' sense of growth through this death experience.
Correct Answer: C
Rationale: It is essential to determine the students' views. Inquiring about the students' perception of the suicide will specifically identify the appraisal of the suicide and the meaning of the perception. Although option 1 is exploratory, it does not address the 'here-and-now' appraisal in terms of the classmate's suicide. Although the nurse is interested in how students have coped in the past, this inquiry should not be the most immediate assessment. Options 2 and 4 are attempts to foster students' self-esteem. Such an approach is premature at this point.
A client awaiting surgery for the removal of a pancreatic mass shares with the nurse concerns about not waking up after receiving the anesthesia. Which therapeutic response is most appropriate for the nurse to make to the client?
- A. This is a very common concern.
- B. Tell me what makes you feel concerned about the anesthesia.
- C. I had surgery a year ago and was afraid of the same thing. I did just fine.
- D. You have the best anesthesiologist in this hospital. There is no need to be scared.
Correct Answer: B
Rationale: This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic response to the client is the one that encourages the client to express her or his concerns. Option 1 is a stereotypical response. Option 3 avoids the client's concern and focuses on the nurse's personal experience. Option 4 also avoids the client's concern.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can implement to assist the parents with developing attachment behaviors?
- A. Support visits by family and friends.
- B. Encourage the parents to touch and speak to their infant.
- C. Report only positive qualities and progress to the parents.
- D. Provide information regarding infant development and stimulation.
Correct Answer: B
Rationale: Parents' involvement through touch and voice establishes and initiates the bonding process in the parent-infant relationship. Their active participation builds their confidence and supports the parenting role. Family visits will not encourage parental attachments. Providing information and emphasizing only positives are not incorrect actions, but they do not relate to the attachment process.