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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A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?
- A. The client is using manipulation to receive secondary gain.
- B. The client is using the defense mechanism of denial.
- C. The client is having trouble terminating the relationship.
- D. The client is using splitting as a way to remain dependent on the nurse.
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates denial of the upcoming change in nurses due to their belief that they are not well enough to switch. This defense mechanism helps the client avoid the reality of the situation. Choice A is incorrect as there is no evidence of manipulation for secondary gain. Choice C is incorrect as the client is not expressing difficulty in terminating the relationship. Choice D is incorrect as splitting involves seeing people as all good or all bad, which is not evident in the client's statement.
During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action?
- A. The nurses action should be evaluated as unacceptable due to breech of cultural norms.
- B. The nurses action should be evaluated as empathetic, encouraging expression of feelings.
- C. The nurses action should be evaluated as the technique of offering self.
- D. The nurses action should be evaluated as inappropriate due to poor timing.
Correct Answer: A
Rationale: The correct answer is A because the nurse's action of hugging the man from Syria who just lost his son in a car accident breaches cultural norms. In many Middle Eastern cultures, physical touch, especially between unrelated individuals of the opposite sex, is considered inappropriate and can be seen as disrespectful. This can cause discomfort and may even offend the individual. In this scenario, the nurse should respect the man's cultural background and find alternative ways to show empathy and support, such as verbal expressions of sympathy or offering a comforting presence.
Choice B is incorrect because while the nurse may have intended to show empathy, the method of hugging was culturally inappropriate. Choice C is incorrect as offering self typically involves sharing personal experiences to build rapport, not physical touch. Choice D is also incorrect as the issue lies more with cultural norms rather than poor timing.
A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear?
- A. Your spouse may be unable to resolve internal conflicts, which result in projected anxiety.
- B. Your spouse may be experiencing a distorted and unrealistic appraisal of the situation.
- C. Your spouse may have a genetic predisposition to overreacting to potential danger.
- D. Your spouse may have high levels of brain chemicals that may distort thinking.
Correct Answer: B
Rationale: The correct answer is B: Your spouse may be experiencing a distorted and unrealistic appraisal of the situation. This aligns with cognitive theory, which focuses on how our thoughts and perceptions influence our emotions and behaviors. In this case, the client's fear of the cruise ship sinking is likely based on an irrational and exaggerated belief rather than a realistic assessment of the situation.
Choice A is incorrect because it focuses on internal conflicts, which may not be directly related to the client's fear of the cruise ship sinking. Choice C is incorrect as genetic predisposition alone is unlikely to explain the specific fear of the cruise ship sinking. Choice D is incorrect as it suggests a biological basis for the fear, whereas cognitive theory emphasizes the role of thoughts and perceptions.
What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?
- A. Acknowledge the clients actions and generate alternative behaviors.
- B. Establish rapport and develop treatment goals.
- C. Attempt to find alternative placement.
- D. Explore how thoughts and feelings about this client may adversely impact care.
Correct Answer: B
Rationale: The correct answer is B: Establish rapport and develop treatment goals. During the introductory phase of the nurse-client relationship, establishing rapport is essential to build trust and a therapeutic alliance. Developing treatment goals collaboratively with the client sets the foundation for the care plan. This action promotes client engagement and empowerment. Acknowledging client actions and generating alternative behaviors (A) is more suited for later phases. Attempting to find alternative placement (C) is not appropriate in the introductory phase. Exploring how thoughts and feelings impact care (D) is important but not the priority during the orientation phase.
An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
- A. The employee assertively confronts the boss
- B. The employee leaves the staff meeting to work out in the gym
- C. The employee criticizes a coworker
- D. The employee takes the boss out to lunch
Correct Answer: C
Rationale: Displacement is a defense mechanism where emotions are redirected from the original source to a substitute target. In this case, the employee is likely to displace their anger from the boss onto a coworker by criticizing them. This behavior allows the employee to express their feelings indirectly.
A: Assertively confronting the boss does not align with displacement as it involves direct confrontation.
B: Leaving the meeting to work out in the gym is a form of avoidance and does not involve displacing emotions onto another target.
D: Taking the boss out to lunch is more of a conciliatory gesture and does not involve displacing negative emotions onto someone else.