Nokea
A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?
- A. The client is placed in seclusion.
- B. The client is placed in a geriatric chair with tray.
- C. The client is placed in soft Posey restraints.
- D. The client is monitored by an ankle bracelet.
Correct Answer: D
Rationale: The correct answer is D - The client is monitored by an ankle bracelet. This option allows for monitoring and tracking the client's movements without physical restraint, promoting autonomy and freedom of movement. Seclusion (A) is restrictive and isolating. Placing the client in a geriatric chair with tray (B) limits mobility and can be degrading. Soft Posey restraints (C) restrict movement and can lead to physical and psychological harm. An ankle bracelet (D) is the least restrictive option as it allows for monitoring while still allowing the client some independence and mobility.
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According to Eriksons developmental theory, when planning care for a 47-year-old client, which developmental task should a nurse identify as appropriate for this client?
- A. To achieve a sense of self-confidence and recognition from others
- B. To reflect back on life events to derive pleasure and meaning
- C. To achieve established life goals and consider the welfare of future generations
Correct Answer: B
Rationale: In Erikson's theory, the developmental task for a 47-year-old client aligns with the stage of Generativity vs. Stagnation. Choice B, reflecting on life events for pleasure and meaning, corresponds to this stage where individuals assess their accomplishments and seek fulfillment. This phase involves contributing to society and future generations. Choice A pertains to the earlier stage of Identity vs. Role Confusion in adolescence. Choice C aligns with the later stage of Integrity vs. Despair in older adulthood. Choice D is incomplete. Therefore, the correct answer is B as it best fits the age and developmental stage of the client in question.
A Native American client is admitted to an emergency department (ED) with an ulcerated toe secondary to uncontrolled diabetes mellitus. The client refuses to talk to a physician unless a shaman is present. Which nursing intervention is most appropriate?
- A. Assist the client in contacting a shaman of his choice.
- B. Explain to the client that voodoo medicine will not heal the ulcerated toe.
- C. Ask the client to explain what the shaman can do that the physician cannot.
- D. Inform the client that refusing treatment is a clients right.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Cultural Competence: In respecting the client's cultural beliefs and practices, it is essential to honor the request for a shaman's presence.
2. Collaboration: By assisting the client in contacting a shaman, the nurse promotes collaboration between traditional healing methods and medical interventions.
3. Trust Building: Respecting the client's request fosters trust and rapport, which are crucial for effective communication and care.
4. Patient-Centered Care: This approach aligns with the principle of patient-centered care, where the client's preferences and values are prioritized.
Summary of Other Choices:
B: This choice is dismissive and disrespectful of the client's beliefs, potentially causing harm by undermining trust and rapport.
C: This choice puts the client on the defensive and does not address the immediate need for a shaman's presence.
D: This choice fails to address the client's request and focuses on the right to refuse treatment, which is not the immediate concern in
Which therapeutic communication technique is being used in this nurseclient interaction? Client: When I get angry, I get into a fistfight with my wife or I take it out on the kids. Nurse: I notice that you are smiling as you talk about this physical violence.
- A. Encouraging comparison
- B. Exploring
- C. Formulating a plan of action
- D. Making observations
Correct Answer: D
Rationale: The correct answer is D, Making observations. The nurse is objectively stating what they notice, which is the client smiling while discussing physical violence. This technique helps bring awareness to the client's behavior without judgment. Encouraging comparison (A) involves asking the client to compare similarities and differences, which is not present in this interaction. Exploring (B) involves delving deeper into the client's thoughts and feelings, which is not demonstrated here. Formulating a plan of action (C) involves working with the client to create a plan for addressing issues, which is not the focus of the nurse's statement.
A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred?
- A. These clients do not recognize that their fear is excessive, and they rarely seek treatment.
- B. These clients have overwhelming symptoms of panic when exposed to the phobic stimulus.
- C. These clients experience symptoms that mirror a cerebrovascular accident (CVA).
- D. These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.
Correct Answer: B
Rationale: The correct answer is B because it accurately describes a key feature of specific phobias: individuals experience intense panic symptoms when exposed to the phobic stimulus. This indicates learning as it demonstrates understanding of the characteristic behavioral response in specific phobias. Choice A is incorrect as it describes characteristics of agoraphobia, not specific phobias. Choice C is incorrect as it describes symptoms of a stroke, not specific phobias. Choice D is incorrect as it lists symptoms that are not typically associated with specific phobias.
A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse should associate this response with which neurotransmitter?
- A. Dopamine
- B. Serotonin
- C. Norepinephrine
Correct Answer: C
Rationale: The correct answer is C, Norepinephrine. During the fight-or-flight response, the sympathetic nervous system is activated, leading to the release of norepinephrine. Norepinephrine increases heart rate, blood pressure, and alertness, preparing the body to either fight or flee from a perceived threat. Dopamine (A) is more related to reward and pleasure. Serotonin (B) is involved in regulating mood and emotions. Cortisol (D) is a stress hormone, not a neurotransmitter involved in the fight-or-flight response.