Nokea
A female client with the diagnosis of mania emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. Which intervention should the nurse implement first?
- A. Quietly approach the client and escort her to her room to get dressed.
- B. Confront the client on the inappropriateness of her behavior and offer her a time out.
- C. Ask the other clients to ignore her behavior; eventually she will return to her own room.
- D. Approach the client in the hallway and insist that she go to her own room immediately.
Correct Answer: A
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety for the client. Insisting that the client go to her room may cause the nurse to be met with a great deal of resistance. Confronting the client and offering her a consequence of time out may be meaningless to her. Asking other clients to ignore her is inappropriate. A quiet but firm approach while distracting the client (walking her to her room and helping her to get dressed) achieves the goal of having the client dressed appropriately and preserving her psychosocial integrity.
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The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a 'tearing' sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the nurse make?
- A. Try not to worry, you and your baby are in good hands.'
- B. I understand your concerns. I'll let your health care provider know you need to talk.'
- C. I don't have time to answer questions now but I'll plan for us to have time to talk later.'
- D. I can understand that you are fearful. We are doing everything possible for your baby.'
Correct Answer: D
Rationale: Clients have a concern for the safety of their baby during labor and delivery, especially when a problem arises. Empathy and a calm attitude with realistic reassurances are important aspects of client care. Dismissing or ignoring the client's concerns can lead to increased fear and a lack of cooperation. Option 1 uses a cliché and provides false reassurance. Options 2 and 3 place the client's feelings on hold.
Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?
- A. Asking to speak to someone
- B. Asking to be alone
- C. Listening to music
- D. All of the above
Correct Answer: D
Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.
A client diagnosed with severe preeclampsia is admitted to the hospital. The client is a student at a local college and insists on continuing her studies while in the hospital, despite being instructed to rest. The client studies approximately 10 hours a day and has numerous visits from fellow students, family, and friends. Which intervention should the nurse use to best assist the client with promoting rest?
- A. Ask her why she is not complying with the prescription for bed rest.
- B. Develop a routine with the client to balance her studies and her rest needs.
- C. Include a significant other in helping the client understand the need for bed rest.
- D. Instruct the client that the health of the baby is more important than her studies at this time.
Correct Answer: B
Rationale: Option 2 involves the client in the decision-making process. In options 1 and 4 the nurse is judging the client's choices and asking probing questions; this will cause a breakdown in communication. Option 3 persuades the client's significant other to disagree with the client's actions. This could cause problems with the relationship between the client and the significant other, and it could also cause conflict in the client's communication with the health care workers.
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client?
- A. Noting whether the client has visitors
- B. Instructing all staff members to not touch the client
- C. Giving the client a roommate with TB who persistently tries to talk
- D. Removing the calendar and clock in the room so that the client will not obsess about time
Correct Answer: A
Rationale: The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and should identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
- A. Improved sleep patterns
- B. Reduced family fears and anxiety
- C. Meeting self-care needs independently
- D. Increased ability to concentrate and participate in care
Correct Answer: D
Rationale: The client needs to be able to concentrate and participate in her or his care. When the client is able to do that, the nurse can work with the client to achieve the other outcomes. Options 1 and 3 address physiological needs rather than psychosocial outcomes. Option 2 is a secondary need and does not address the client.