Nokea
A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. "Tell me about the concerns that you have regarding your relationship."
- B. "You should try to see your partner’s point of view before your own."
- C. "We could develop a plan for how to talk about this with your partner."
- D. "Relationship difficulties are stressful and require effort to resolve."
Correct Answer: B
Rationale: The correct answer is B. This statement implies a bias towards the partner's perspective, potentially invalidating the client's feelings. The nurse should prioritize understanding the client's concerns first. A is correct as it encourages open communication. C shows proactive problem-solving. D acknowledges the challenges of resolving relationship issues.
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A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?
- A. "You will need to consume a low-salt diet while on this medication."
- B. "You will need your blood levels drawn weekly during the first month."
- C. "You will need to take this medication on an empty stomach."
- D. "You will need to stop this medication if you experience diarrhea."
Correct Answer: B
Rationale: Lithium levels need frequent monitoring at the start of therapy to prevent toxicity.
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 who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior?
- A. Automatic obedience
- B. Waxy flexibility
- C. Negativism
- D. Impaired impulse control
Correct Answer: C
Rationale: The correct answer is C: Negativism. Negativism is a behavior where the client does the opposite of what is asked or expected. In this case, the client with schizophrenia consistently does the opposite of what the nurse asks, which aligns with negativism. Automatic obedience (A) is when a client complies without question, waxy flexibility (B) is characterized by maintaining limbs in the position they are placed in, and impaired impulse control (D) involves difficulty controlling impulses, none of which fit the scenario described.
A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
- A. "So, it seems that you feel responsible for what happened to your mother."
- B. "Your mother will be fine. You shouldn't worry so much."
- C. "Why do you blame yourself? You could not have prevented the stroke."
- D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A is the correct response because it acknowledges the son's feelings without dismissing or invalidating them. It shows empathy and understanding towards his guilt, opening up a conversation for further exploration of his emotions. It reflects active listening and validates his concerns.
Summary of Incorrect Choices:
B: This response minimizes the son's feelings and does not address his sense of guilt, which can further exacerbate his emotional distress.
C: While this response provides reassurance, it does not address the son's feelings of guilt and may come off as dismissive.
D: This response acknowledges the son's feelings but does not directly validate his sense of responsibility, missing an opportunity for therapeutic communication.
A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?
- A. "Yes, I understand that you feel better wearing your bracelet."
- B. "Why do you think the copper helps with your arthritis?"
- C. "Believing objects have powers to make you feel better has no scientific basis."
- D. "I think you should rely more on your medication therapy than on your bracelet."
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should acknowledge and validate the client's feelings and beliefs regarding the copper bracelet without dismissing them. By responding with empathy and understanding, the nurse can establish a trusting relationship with the client. This approach can lead to open communication and collaboration in the client's care. It is important to respect the client's perspective and provide support rather than judgment.
Incorrect Choices:
B: Asking the client why she thinks the copper helps may come off as dismissive or confrontational, potentially alienating the client.
C: Dismissing the client's beliefs outright can damage the nurse-client relationship and hinder effective communication.
D: Suggesting the client rely more on medication than the bracelet may be perceived as disregarding the client's preferences and autonomy in managing her condition.