Nokea
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
- A. Identify the client's nutritional status.
- B. Request a mental health consult.
- C. Plan a therapeutic diet for the client.
- D. Provide a structured environment for the client.
Correct Answer: A
Rationale: The correct answer is A: Identify the client's nutritional status. The priority is to assess the client's nutritional status due to the significant weight loss. This will help determine if the client is at risk of malnutrition or other health issues. B, requesting a mental health consult, is not the first priority as addressing the client's physical health is crucial before addressing mental health concerns. Planning a therapeutic diet (C) can come after assessing the nutritional status. Providing a structured environment (D) may be important but not as critical as determining the client's nutritional status first.
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A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
- A. Reaction formation
- B. Compensation
- C. Rationalization
- D. Suppression
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and is now pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client helps provide support while allowing them to work through their anxiety.
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
- A. "I can arrange for a female assistive personnel to do your personal hygiene care."
- B. "The nurse assigned to care for you is very capable and cares for other women in this situation."
- C. "Your doctor is a man, so it seems like this should not be a problem."
- D. "I can review the assignments and arrange for a female nurse to care for you."
Correct Answer: D
Rationale: The correct answer is D. The nurse manager should respect the client's wishes and arrange for a female nurse to care for her. This is important for the client's comfort and sense of safety. Option A only addresses personal hygiene care, not overall nursing care. Option B focuses on the nurse's capabilities, not the client's preferences. Option C is dismissive of the client's concerns and does not address the issue directly. It is essential to prioritize the client's feelings and choices in this sensitive situation.
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?
- A. Place metal utensils on the client’s meal tray
- B. Assign the client to a private room
- C. Inspect the client's personal belongings
- D. Tuck bedcovers over the client’s hands and arms
Correct Answer: C
Rationale: The correct answer is C: Inspect the client's personal belongings. This action is crucial to ensure the safety of the client by identifying any potentially harmful items that could be used for another suicide attempt. Placing metal utensils (A) on the tray could pose a risk. Assigning to a private room (B) may isolate the client further. Tucking bedcovers (D) could restrict movement. Other choices are not relevant.
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving?
- A. The client is 48 years old.
- B. The client's husband died seven months ago.
- C. The client has lost 30 lb.
- D. The client is having difficulty sleeping.
Correct Answer: C
Rationale: The correct answer is C: The client has lost 30 lb. This indicates maladaptive grieving as significant weight loss is a common symptom of unresolved grief. This could be due to appetite changes, neglecting self-care, or depression. Losing a considerable amount of weight can impact physical health and well-being, indicating a need for intervention. Choices A, B, and D are not directly related to maladaptive grieving. Age (A) and the time since the husband's death (B) are not definitive indicators of maladaptive grieving. Difficulty sleeping (D) can be a common symptom of grief but is not as concerning as significant weight loss in this context.