Nokea
A mother states to the nurse, 'I am afraid that my child might have another febrile seizure.' Which therapeutic statement is best for the nurse to make to the mother?
- A. Tell me what frightens you the most about seizures.
- B. Tylenol can prevent another seizure from occurring.
- C. Most children will never experience a second seizure.
- D. Why worry about something that you cannot control?
Correct Answer: A
Rationale: Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.
You may also like to solve these questions
The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?
- A. Place the client in a high Fowler position.
- B. Assist the client in assuming a left side-lying position.
- C. Measure the tube from the tip of the nose to the xiphoid process.
- D. Assist the client in flexing the neck forward to facilitate tube insertion.
Correct Answer: A
Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
- A. At home, I take my pills at 8:00 am.
- B. It costs a lot of money to buy all of these pills.
- C. I get so tired of taking pills every day.
- D. This is a new pill I have never taken before.
Correct Answer: D
Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.
The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best?
- A. You have not done anything wrong. Your spouse is probably experiencing war memories.
- B. Do what is asked. Make the environment quiet and keep your distance until your spouse is less upset.
- C. Approach your spouse calmly and slowly, saying your name and current location.
- D. Touch your spouse's arm gently and ask what is causing the anger.
Correct Answer: B
Rationale: Respecting the veteran’s need for space by keeping the environment quiet and maintaining distance reduces stimulation and potential escalation, especially during possible PTSD episodes. Approaching or touching may increase agitation, and reassurance is less actionable.
The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
- A. The termination stage begins with the initial group meeting.
- B. Members' feelings about their accomplishments are explored in the working stage.
- C. During the working stage, members may be unclear about the purpose of the group.
- D. Group roles and responsibilities are established in the working stage of group therapy.
Correct Answer: D
Rationale: In group therapy, roles and responsibilities are established during the working stage, as members actively engage. Termination (A) occurs at the end, feelings about accomplishments (B) are explored in termination, and unclarity about purpose (C) occurs in the forming stage.
The home health nurse visits a client with cancer undergoing anti-cancer treatment. The nurse asks how the client is coping, and the client cries and with an angry voice says, 'Nobody understands. I am hanging on, trying to take one day at a time, but it is all I can do to get up in the morning.' How does the nurse best respond?
- A. What kind of support do you think would be most helpful to you at this time?
- B. I would be upset too if the people around me didn't act like they cared.
- C. Dealing with family is a challenge, even for people who are feeling healthy.
- D. Why don't you attend a support group for women who are going through the same thing?
Correct Answer: A
Rationale: Asking about desired support empowers the client to express needs, addressing their feelings of being misunderstood. Empathizing without guidance, focusing on family, or suggesting a support group without client input is less client-centered.