Nokea
A client with untreatable metastasized cancer tells the nurse, 'I think they made a mistake. I don't think I have cancer. I feel too good to be dying.' Which stage of grief is the client experiencing?
- A. Anger
- B. Denial
- C. Bargaining
- D. Acceptance
Correct Answer: B
Rationale: The client is experiencing the stage of denial. This is evident as the client is having difficulty accepting the reality of their diagnosis and denies the presence of cancer despite the evidence. During the anger stage, the individual expresses anger about their situation, questioning why it is happening to them. Bargaining involves attempting to negotiate for more time or a different outcome, acknowledging the reality of death but trying to delay it. Acceptance, on the other hand, is characterized by coming to terms with the inevitability of death and preparing for it peacefully. Therefore, in this scenario, the client's disbelief and refusal to accept the diagnosis align with the denial stage of grief.
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Which risk factor for suicide is considered the most lethal?
- A. History of alcohol and drug abuse
- B. Previous high-lethality suicide attempts
- C. Recent withdrawal from friends
- D. Disturbance of family dynamics
Correct Answer: B
Rationale: The correct answer is 'Previous high-lethality suicide attempts.' This is the most lethal risk factor as it indicates that the individual has previously attempted suicide in a manner that could lead to death. This history increases the likelihood of future attempts. While substance abuse, like alcohol and drug use, is a significant risk factor for suicide, it is not considered the most lethal. Withdrawal from friends or social isolation can contribute to suicide risk but is not as directly deadly as high-lethality attempts. Disturbance of family dynamics can also be a stressor but does not represent the immediate lethality associated with a history of high-lethality suicide attempts.
After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. Which response would the nurse provide?
- A. This must be very difficult for you with this added pressure.''
- B. Having a child is a decision you should make without your parents' input.''
- C. You're lucky. It's nice that your parents are making such a generous offer.''
- D. Five years without a pregnancy is a long time. You were right to come to the fertility clinic.''
Correct Answer: A
Rationale: The correct response acknowledges the emotional challenge the couple is facing due to the added pressure of the incentive from the husband's parents. By expressing empathy and understanding, the nurse encourages the couple to open up about their feelings and concerns. Choice B is not the best response as it dismisses the husband's situation and fails to address the emotional impact of the added pressure. Choice C focuses on the parents' offer rather than the couple's emotional state, which is not the primary concern in this situation. Choice D, mentioning the duration of infertility, may come across as insensitive and may hinder open communication by potentially making the couple feel judged or discouraged.
A client is undergoing treatment for alcoholism. Twelve hours after their last drink, they develop tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct Answer: C
Rationale: In alcohol withdrawal, stage 3 typically begins about 12-48 hours after the last drink. It includes symptoms from stages 1 and 2 like tremors, tachycardia, mild hallucinations, hyperactivity, and confusion. By stage 3, severe hallucinations and seizures can occur. Choice A, stage 1, is too early for the described symptoms. Stage 2, as described, is also too early as it typically occurs within 6-12 hours. Stage 4 is not a recognized stage in alcohol withdrawal protocols.
What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?
- A. "I see that you're worried. We're using medication to ease your wife's discomfort."?
- B. "This is expected. I suggest that you go home because there's nothing you can do to help."?
- C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification."?
- D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."?
Correct Answer: A
Rationale: The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.
Under what patient conditions or situations are restraints sometimes used?
- A. As punishment when the patient is uncontrollable
- B. To prevent the patient from pulling their IV out
- C. When a patient is a danger to self and others
- D. Both B and C
Correct Answer: D
Rationale: Restraints are sometimes used to prevent a patient from pulling out their IV or another life-saving tube and when the person poses a serious danger to themselves and/or others. Restraints are never used as a form of punishment. Choice A is incorrect because restraints are not utilized for punishment but for patient safety and care. Choice B and C are correct because they reflect the appropriate and necessary situations where restraints may be used in healthcare settings.