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A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?
- A. Why did you make the choice to behave negatively?
- B. I understand that you are angry. However, I followed the appropriate protocol.
- C. You need to calm down and forgive me before discussing this matter any further.
- D. You were made aware of the consequences of negative behavior, so you better go to your room.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions while also asserting boundaries and explaining the nurse's actions. By stating, "I understand that you are angry. However, I followed the appropriate protocol," the nurse shows empathy towards the client's feelings and also maintains professionalism by emphasizing adherence to established procedures. This response validates the client's emotions and provides clarity on the nurse's decision-making process, promoting open communication and understanding.
Choices A, C, and D are incorrect because they lack empathy, fail to acknowledge the client's emotions, or use directive language that may escalate the situation. Choice A focuses on blaming the client, Choice C dismisses the client's feelings, and Choice D is authoritative and may trigger defensiveness.
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A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Bizarre behavior
- B. Waxy flexibility
- C. Somatic delusions
- D. Illogicality
Correct Answer: B
Rationale: Waxy flexibility reflects a lack of normal movement a negative symptom of schizophrenia.
A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?
- A. Let's discuss what you mean when you say that you cannot ever return to work.
- B. You need to work hard on resolving conflict with those closest to you.
- C. Antidepressants are not your solution, but this therapy group is.
- D. I notice you keep clenching your fists. Why are you doing this?
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A demonstrates active listening and encourages further exploration of the client's feelings and perspectives. It shows empathy and promotes open communication. It allows the nurse to understand the client's concerns about returning to work and address them effectively.
Summary:
B: This choice is not appropriate as it focuses on resolving interpersonal conflicts rather than addressing the client's concerns about their diagnosis.
C: This choice dismisses the potential need for medication and minimizes the importance of therapeutic support.
D: This choice addresses a physical behavior without directly addressing the client's emotional concerns about work.
A nurse is caring for a client who reports increased anxiety and nervousness,heat intolerance,and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH),elevated thyroxine (T4) and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
- A. Hypotension
- B. Tachycardia
- C. Slow respiratory rate
- D. Decreased body temperature
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. In this scenario, the client is showing symptoms of hyperthyroidism, such as increased anxiety, nervousness, heat intolerance, and unintentional weight loss. The decreased TSH and elevated T4/T3 levels indicate an overactive thyroid gland.
Tachycardia is a common symptom of hyperthyroidism due to the increased metabolic rate caused by excess thyroid hormones. The body's response to the increased metabolism is to speed up the heart rate to meet the increased demand for oxygen and nutrients. Therefore, the nurse can anticipate tachycardia in this client.
The other options are incorrect because hypotension is not typically associated with hyperthyroidism; slow respiratory rate is not a common vital sign abnormality seen in hyperthyroidism; decreased body temperature is unlikely as hyperthyroidism usually causes heat intolerance and increased body temperature.
A nurse is caring for a client who is newly diagnosed with hyperthyroidism and reports dry eyes and sensitivity to light. The nurse notes that the client's eyes have a bulging appearance. Which of the following should the nurse include in the client's plan of care?
- A. Exposure to sunlight will help to strengthen your eyes.
- B. These are unusual symptoms. I will ask the provider for an ophthalmology referral.
- C. Eye drops and dim lighting can improve your symptoms.
- D. Surgery will be necessary to correct the damage to your eyes.
Correct Answer: C
Rationale: The correct answer is C: Eye drops and dim lighting can improve your symptoms. In hyperthyroidism, the bulging appearance of the eyes, known as exophthalmos, can lead to dry eyes and sensitivity to light. Eye drops can help alleviate dryness, and dim lighting can reduce discomfort from light sensitivity. This intervention addresses the client's specific symptoms and promotes comfort.
Choice A is incorrect because sunlight exposure can exacerbate light sensitivity in clients with hyperthyroidism. Choice B is incorrect as it does not provide a direct intervention for the client's symptoms and delays addressing the discomfort. Choice D is incorrect because surgery is not typically the first-line treatment for eye symptoms in hyperthyroidism; conservative measures are usually tried first.
The nurse is teaching a client about cellular hypertrophy. Which statement should be included in the teaching?
- A. It's uncontrolled proliferative cell growth that is cancerous.
- B. It's the enlargement of an organ or tissue from the increase in cell size.
- C. It's the wasting away of tissue or organs.
- D. It's the abnormal growth or development of cells.
Correct Answer: B
Rationale: The correct answer is B because cellular hypertrophy refers to the increase in the size of cells leading to the enlargement of an organ or tissue. This is a normal physiological response to increased demand or stress. Choice A is incorrect as uncontrolled proliferative cell growth leading to cancer is known as neoplasia, not hypertrophy. Choice C is incorrect as wasting away of tissue is termed as atrophy, not hypertrophy. Choice D is incorrect as abnormal cell growth or development is more indicative of dysplasia or metaplasia, not hypertrophy.