Nokea
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: The correct answer is denial. In this scenario, the client's statement indicates denial, which is a common reaction in Kübler-Ross's Stages of Grieving. Denial involves the refusal to accept or believe that a loss, such as a terminal illness diagnosis, is happening. Choices B, C, and D are incorrect: Anger involves feelings of resentment or frustration; Bargaining is an attempt to negotiate or make deals to avoid the situation; Acceptance is the final stage where the individual comes to terms with the reality of the situation.
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Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood?
- A. Document the vomiting.
- B. Increase the IV fluids.
- C. Get a complete blood count.
- D. Check the blood pressure.
Correct Answer: D
Rationale: The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later.
Which is the proper hand position for performing chest percussion?
- A. cup the hands
- B. use the side of the hands
- C. flatten the hands
- D. spread the fingers of both hands
Correct Answer: A
Rationale: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.
A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, 'No woman will ever want to marry me now.' Which of the following responses by the nurse is most therapeutic?
- A. Don't worry. Maybe you'll meet a paraplegic woman.'
- B. There is someone for everyone in this world.'
- C. You are still an attractive man, even though you can't walk.'
- D. Tell me more about your feelings on this issue.'
Correct Answer: D
Rationale: This response is the most therapeutic because it allows the client to discuss his anxieties and fears with the nurse. The other responses do not allow for such a dialogue, so they are not as therapeutic.
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct Answer: C
Rationale: Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. What should the health care worker do?
- A. Immediately contact child protective services.
- B. Provide the mother with literature about child care.
- C. Consult a therapist to help the mother work out her fears.
- D. Refer the mother to parenting classes.
Correct Answer: D
Rationale: When a health care worker is concerned about a new mother being overwhelmed by caring for her infant, the best course of action is to refer the mother to parenting classes. Prevention of child abuse is focused on educating parents on how to care for their child and handle the demands of infant care. By attending parenting classes, the mother can build self-confidence, self-esteem, and coping skills. Parenting classes help parents understand the developmental needs of their children and learn effective ways to manage their home environment. Additionally, these classes provide parents with increased social contacts and knowledge about community resources. Contacting child protective services (choice A) should not be the immediate action as there is no indication of abuse. Providing literature about child care (choice B) may not be as effective as hands-on parenting classes. Consulting a therapist (choice C) may be beneficial, but addressing parenting skills through classes is more appropriate in this scenario.