Nokea
A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client's dichotomous tendency?
- A. I am glad you like me. Which nurse was acting aloof to you?
- B. Tomorrow I will talk to that nurse about how you were treated last night.
- C. What did the night nurse do that makes you think she is aloof?
- D. I am happy that you are getting better and will be able to go home.
Correct Answer: A
Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
You may also like to solve these questions
What is the primary focus of postoperative nursing care for the client with colon trauma?
- A. Monitoring for elevated coagulation studies
- B. Observation for and prevention of fistulas
- C. Monitoring for signs of hyponatremia
- D. Observation for and prevention of infection
Correct Answer: D
Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.
A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?
- A. Heart rate and blood pressure
- B. Blood glucose levels
- C. Respiratory rate
- D. Liver function tests
Correct Answer: A
Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.
The mother of a school-age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse's best response?
- A. When all live lice are eliminated by the treatment
- B. Two weeks after the last treatment
- C. As soon as the itching stops
- D. After the treatment kills all the live lice
Correct Answer: D
Rationale: The correct answer is 'After the treatment kills all the live lice.' The child can return to school once all live lice are eliminated to prevent the spread of Pediculosis capitis. This is essential as live lice are highly contagious. Choices A, B, and C are incorrect. Waiting for the itching to stop or for an epidemic to subside does not ensure that all live lice are eradicated, which is crucial to prevent reinfestation and transmission.
What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?
- A. Take this medication with or without food
- B. Avoid using heat or ice on injured muscles while taking this medication
- C. Use cold and allergy medications only as directed by a healthcare provider
- D. Discontinue all nonsteroidal anti-inflammatory medications
Correct Answer: C
Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.
A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?
- A. Review the current treatment plan with the client
- B. Inform the healthcare provider about the client's behaviors
- C. Determine if the client has PRN medication for anxiety
- D. Explore the client's reasons for wanting to be discharged
Correct Answer: D
Rationale: Exploring the client's reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.