Nokea
A mother complains to the nurse that her 3-year-old child refuses to go to preschool. The child rarely interacts and avoids playing with other children. Which statement would the nurse provide?
- A. Do not be concerned because all toddlers behave this way.
- B. Ask the teacher to push the child to speak up and open up to the other kids.
- C. Set boundaries and supervise the child closely.
- D. Give your child time to get acquainted and warm up to the new environment.
Correct Answer: D
Rationale: According to the mother's description, the child is a slow-to-warm-up child. These children are uneasy in new situations or with unfamiliar people. The nurse would educate the mother to give the child time to be more familiar with the new environment. All toddlers do not behave in the same manner. A slow-to-warm-up child should not be pressured to do anything against his or her wishes. Setting boundaries and closely supervising the child is not the best approach for a child who needs time to adapt. Asking the teacher to push the child to open up can create more anxiety and stress for the child, which is not recommended.
You may also like to solve these questions
Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage?
- A. Choosing creative ways to promote social participation
- B. Providing information to the client about the treatment plan
- C. Encouraging the client to participate actively in treatment procedures
- D. Involving the client's partners or family members in the caring process
Correct Answer: B
Rationale: During the identity versus role confusion stage, which occurs during adolescence or puberty, it is essential for the nurse to empower hospitalized adolescents by providing them with sufficient information about their treatment plan. This approach enables the clients to actively participate in decision-making regarding their care. Choosing creative ways to promote social participation is more aligned with assisting clients during the generativity versus self-absorption and stagnation stage, where fostering social engagement can contribute to a sense of fulfillment. Involving the client's partners or family members in the caring process is typically beneficial during the intimacy versus isolation stage to create a strong support system for the client. Encouraging active participation in treatment procedures is more relevant to the industry versus inferiority stage, ensuring that the hospitalized client engages effectively in their care.
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching?
- A. I check my weight every day without fail.'
- B. I exercise 3 to 4 hours every day to keep my slim figure.'
- C. I've been told that I am 10% below my ideal body weight.'
- D. My best friend was in the hospital with this disorder a year ago.'
Correct Answer: B
Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being.
When developing Jerry's plan of care, which of the following would NOT be helpful to include?
- A. Limiting choices
- B. Providing structure
- C. Encouraging patient input
- D. Ensuring availability of PRN medications
Correct Answer: A
Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.
When attempting to incorporate the Latino client's cultural background into the plan of care, which consideration is the most important?
- A. Socioeconomic considerations regarding hospitalization
- B. The meaning and attention the client places on the future
- C. The client's need to control care to ensure desired outcomes
- D. Inclusion of the family in the plan of care with the client's permission
Correct Answer: D
Rationale: The most important consideration when incorporating the Latino client's cultural background into the plan of care is the inclusion of the family in the care plan with the client's permission. In Latino cultures, family plays a vital role, and there is a strong emphasis on family support during challenging times. This support can positively impact the client's health outcomes and overall well-being. Socioeconomic status, although relevant, does not carry more weight than usual in healthcare decisions. Latino clients typically focus on the present rather than the future, and they often attribute outcomes to external factors like fate or divine intervention. While the client's need for control is important, involving the family aligns more closely with the cultural values and preferences of Latino clients.
The client states to the nurse, 'I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?' Which statement by the nurse is the most therapeutic?
- A. Don't worry about the details. This procedure is done all the time and generally without any problems. You'll be fine!'
- B. They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I'll come.'
- C. Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can't be too careful.'
- D. You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?'
Correct Answer: D
Rationale: The client has verbalized concerns. In option 4, the nurse uses reflection to direct the client's feelings and concerns. In option 1 the nurse provides false reassurance and then minimizes the client's concerns. In option 2 the nurse is ventilating the nurse's own anger, frustration, and powerlessness. In addition, the nurse is trying to problem-solve for the client but is overly controlling and takes the decision making out of the client's hands. In option 3, the nurse is projecting the client's own fears, and the problem-solving suggested by the nurse will increase fear and anxiety in the client.