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A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions
- B. making a baseline record of the time the wife spends cleaning
- C. decreasing the stimuli in the home
- D. helping his wife with the cleaning
Correct Answer: C
Rationale: Reducing environmental stimuli can decrease anxiety driving obsessive-compulsive cleaning, supporting therapy without confronting or enabling the behavior.
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When planning intervention for a client during a crisis, which of the following outcomes is most appropriate?
- A. The client should explore deep psychological problems.
- B. The client should express positive feelings about event.
- C. The client should identify needs that are threatened by the event.
- D. The client should use constructive coping mechanisms.
Correct Answer: D
Rationale: The primary goal of crisis intervention is to relieve the symptoms of anxiety and foster constructive coping. Previous psychological issues might recur during crisis, but the focus is on short-term resolution of the current problem. At the end, the nurse credits a client for positive changes and helps him or her understand what was learned. This allows the client to use the learned coping mechanisms when new problems arise.
A client recently lost a child due to poisoning. The client tells the nurse, 'I don't want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional behavioral indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The client's withdrawal from forming new relationships reflects a sociocultural indicator of stress, as it affects social interactions. Emotional behavioral indicators involve mood changes, spiritual indicators relate to existential concerns, and intellectual indicators involve cognitive difficulties.
What are the implications for a client with renal insufficiency who wants to start a low-carbohydrate (CHO) diet?
- A. As long as the client eats a minimum of 30 g of CHO/day, there should be no problem.
- B. The client's clinical condition is a contraindication to starting a low CHO diet.
- C. Calcium supplements should be utilized to prevent the development of osteoporosis while on a low CHO diet.
- D. As long as the client eats foods that are high biologic protein sources, a low CHO diet can be followed.
Correct Answer: B
Rationale: A client with renal insufficiency should not start a low CHO diet because it could result in an increased renal solute load. Clients who have renal disease (renal failure, endstage renal disease [ESRD], dialysis, and transplant) or liver disease (liver failure, hepatic encephalopathy, cirrhosis, transplant, and hepatitis) require some form of protein control in dietary patterns to prevent complications from an inability to handle protein solute load. Proteins used in the diet must be of high biologic value, and protein intake is usually weight based, starting at 0.8 g/kg of dry weight, depending on the client's underlying clinical condition. Protein levels may be increased as necessary to account for metabolic response to dialysis and regeneration of liver tissue (1.5-2.0 g/kg/day). A minimum level of CHOs are needed in the diet (50-100 g/day) to spare protein. Vitamin and mineral supplements might be indicated with clients who have liver failure. The dietician is instrumental in calculating specific nutrient requirements for these clients and reviewing fluid intake and output, medication profile, and daily weight to monitor client outcomes in conjunction with dialysis technicians and nurses.
In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
- A. whole brain death.
- B. heart-lung death.
- C. circulatory death.
- D. higher brain death.
Correct Answer: A
Rationale: Most protocols require two separate clinical examinations, including induction of painful stimuli, papillary responses to light, oculovestibular testing, and apnea testing. Heart-lung and higher brain death have no specific test required. Circulatory death is not a current definition of death in the United States.
The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
- A. elevated blood pressure.
- B. Cheyne-Stokes respiration.
- C. elevated pulse rate.
- D. decreased temperature.
Correct Answer: B
Rationale: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.