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A nurse in the outpatient clinic receives four phone messages. Which call does the nurse return first?
- A. The parent of a preschool-age child who continuously throws temper tantrums, is always moving, and is impulsive.
- B. The parent whose adolescent child has vomited every day for 2 weeks and now weighs 74 pounds.
- C. The parent who receives calls from the school about an adolescent child's aggressive behavior toward schoolmates.
- D. The adult child of an older adult who is having difficulty sleeping after a spouse died 2 weeks ago.
Correct Answer: B
Rationale: An adolescent vomiting daily for 2 weeks and weighing 74 pounds indicates a critical health issue, likely severe dehydration or malnutrition, requiring urgent assessment to prevent life-threatening complications. This takes priority over behavioral, aggression, or grief-related concerns.
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The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement?
- A. A brain tumor presents with few sights/symptoms.
- B. It is true that brain tumors are easily recognizable.
- C. Brain tumors are never detected until very late in their course.
- D. The signs/symptoms of a brain tumor may be easily attributed to another cause.
Correct Answer: D
Rationale: Signs and symptoms of a brain tumor vary depending on location, and they may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and changes in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them during the normal grieving process. Options 1, 2, and 3 are inaccurate statements.
A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will be required. The client becomes angry and states, 'I'll never be the same now.' Based on this information, which should the nurse identify as the client's primary concern?
- A. Anxiety about the hemodialysis
- B. Inability to think clearly because of the treatments needed
- C. Potential for noncompliance because of concerns about the disease
- D. Altered body image because of the physical changes that may occur
Correct Answer: D
Rationale: A client with a renal disorder such as CKD may become angry in response to the permanence of the condition. Because of the physical changes and the change in lifestyle that may be required to manage a severe renal condition, the client may experience an altered body image. Anxiety is not appropriate because the client is exhibiting anger at this time. The client is not cognitively impaired, eliminating option 2, and is not stating a refusal to undergo therapy, so eliminate option 3.
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, 'Rain, train, down the drain, Jane's brain.' The nurse recognizes this type of speech pattern as which type?
- A. echolalia
- B. word salad
- C. neologisms
- D. clang association
Correct Answer: D
Rationale: Clang association is characterized by words chosen for their sound (e.g., rhyming or alliteration) rather than meaning, as seen in the client's response.
While in the dining area, an adult client at the retirement center yells, 'This turkey is dry and cold! I can't stand the food here!' Which is the best response by the nurse to the client's behavior?
- A. Now look what you've done! You're ruining this meal for the whole community. Aren't you ashamed of yourself?
- B. I think you had better return to your apartment now. I'll make arrangements for a new meal to be served to you there.
- C. Let me get you another serving that is more to your liking. Would you like to see the chef and select your own serving?
- D. One of the things that was agreed upon was that anyone who did not use appropriate behavior would be asked to leave the dining room. Please leave now.
Correct Answer: C
Rationale: Asking the client to accompany the nurse to the kitchen respects the client's need for control, removes the angry client from the dining room, and may offer the nurse an opportunity to assess what is happening with the client. Agency procedure should be followed regarding those who are allowed access to the facility kitchen. Option 1 is angry, aggressive, and nontherapeutic. Option 2 could provoke a regressive struggle between the nurse and the client and cause more anger in the client. In option 4, the nurse is authoritative, and it would not be appropriate to ask the client to leave. This action may set up an aggressive struggle between the nurse and the client.