Nokea
A nurse is caring for a client who has a new diagnosis of chronic renal failure. The nurse should recognize which of the following client statements as an indication of anticipatory grief?
- A. I know that I will get a kidney transplant. I am a good candidate.
- B. I can now eat whatever I want. It will be dialyzed out of my system.
- C. I just can't believe that my whole life is going to be ruined by dialysis.
- D. I know that renal failure runs in my family and I can prevent it.
Correct Answer: C
Rationale: The correct answer is C because the statement reflects a sense of loss and mourning over the potential impact of the diagnosis on the client's life. Anticipatory grief involves feelings of sadness, anxiety, and loss before an actual event occurs. Option A shows hope and optimism, not anticipatory grief. Option B indicates a lack of understanding about the seriousness of the condition. Option D demonstrates a focus on prevention rather than grieving.
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A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?
- A. Dilated pupils
- B. Dysrhythmias
- C. Diarrhea
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B: Dysrhythmias. Straining while defecating can increase intra-abdominal pressure, leading to a vagal response that triggers dysrhythmias in susceptible individuals. This can be particularly dangerous for older adults with underlying heart conditions. Dilated pupils (choice A) are not directly related to straining during defecation. Diarrhea (choice C) is the opposite of constipation and is not a common consequence of straining. Gastric ulcers (choice D) are typically caused by factors such as H. pylori infection or NSAID use, not straining during defecation.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop gross motor skills around 2 years old, making riding a tricycle a suitable activity. Jumping rope (choice A) requires more advanced coordination and balance. Printing letters and numbers (choice C) involves fine motor skills that develop later. Using scissors (choice D) also requires more advanced fine motor skills.
A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?
- A. Determine the reason the client sought care.
- B. Instruct the client about methods to achieve goals.
- C. Discuss the client's new skill sets.
- D. Review the client's demographic information.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client about methods to achieve goals. During the working phase of a therapeutic relationship, the nurse focuses on helping the client achieve their goals through guidance, education, and collaboration. Instructing the client about methods to achieve goals empowers them to actively participate in their care and progress towards wellness. This action promotes client autonomy and self-efficacy, key components of a therapeutic relationship.
Incorrect choices:
A: Determining the reason the client sought care is typically done in the initial phase of the relationship.
C: Discussing the client's new skill sets may be more appropriate in the termination phase where progress is reviewed.
D: Reviewing the client's demographic information is necessary but not a primary action during the working phase.
A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
- A. Use a cotton-tipped applicator to remove cerumen.
- B. Pull the pinna downward and backward.
- C. Aim the probe posteriorly in the direction of the eardrum.
- D. Insert the probe with a circular motion.
Correct Answer: C
Rationale: The correct answer is C because aiming the probe posteriorly in the direction of the eardrum allows for accurate tympanic temperature measurement. This ensures that the infrared sensor is positioned correctly to capture the heat emitted from the tympanic membrane. Choice A is incorrect as removing cerumen is not necessary for temperature measurement. Choice B is incorrect as pulling the pinna downward and backward is not required for tympanic temperature measurement. Choice D is incorrect as inserting the probe with a circular motion may cause discomfort or injury to the ear canal.
A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?
- A. Serve foods that have a hot/cold balance.
- B. Serve milk products prior to meals
- C. Request a meal tray without pork.
- D. Remove tea and coffee from meal trays.
Correct Answer: C
Rationale: Muslim dietary laws prohibit pork, so meals should be planned accordingly.