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A nurse is performing an assessment interview of a 14-year-old boy who is being admitted to an adolescent substance abuse unit. His parents are concerned about their son's repeated problems at school that they associate with his drug use. The boy stalks into the office, abruptly sits down, crosses his arms, and says, 'Okay, ask your stupid questions, but don't expect me to cooperate!' Which response by the nurse would be most appropriate?
- A. Your attitude is offensive; I can see why your parents brought you here.
- B. Why don't we wait until you've calmed down a bit to start the interview?
- C. Why are you so angry?
- D. You seem pretty upset. Tell me about what is upsetting you.
Correct Answer: D
Rationale: The correct response is D because it acknowledges the boy's emotions, shows empathy, and invites him to share his feelings. By acknowledging his upset feelings, the nurse can build rapport and establish trust, which is crucial in therapeutic communication. This response also opens the door for the boy to express himself and potentially reveal the underlying reasons for his behavior.
Choices A and C are confrontational and judgmental, which can escalate the situation and hinder communication. Choice B suggests waiting until the boy calms down, which may be dismissive of his emotions and doesn't address the immediate need for connection and understanding.
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A nurse engaged in an interaction with a patient recognizes body space zones. Which of the following would the nurse identify as the individual's personal zone?
- A. Beginning at the boundary of the intimate zone and ending at the social zone
- B. Extending outward from the border to the public zone
- C. Surrounding and protecting an individual from others, especially outsiders
- D. The most distant boundary that can be used for recognizing intruders
Correct Answer: A
Rationale: The correct answer is A because the personal zone is the space ranging from 18 inches to 4 feet from an individual, which falls between the intimate zone (0-18 inches) and the social zone (4-12 feet). This zone is where most interactions with acquaintances occur.
Choice B is incorrect because the public zone extends beyond the social zone and is typically used for public speaking or formal presentations.
Choice C is incorrect because it describes the concept of a protective or defensive space, not the personal zone.
Choice D is incorrect because the concept of recognizing intruders pertains more to territoriality and is not specific to identifying personal space zones.
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?
- A. Offering hope allays and defuses the patient's anxiety.
- B. Concerns stated aloud become less overwhelming and help problem solving begin.
- C. Anxiety is reduced by focusing on and validating what is occurring in the environment.
- D. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
Correct Answer: B
Rationale: The correct answer is B because verbalizing feelings and concerns can help the patient process and understand their emotions, making them feel less overwhelming. This can facilitate problem-solving by breaking down complex issues into smaller, manageable parts. By talking about their concerns, the patient can also receive support and feedback from the nurse, leading to a sense of relief and empowerment.
Incorrect answer explanations:
A: Offering hope may be comforting but does not directly address the patient's current anxiety by helping them process and verbalize their feelings.
C: Focusing on the environment may not necessarily address the patient's internal feelings and concerns, which are key in managing anxiety.
D: While exploring alternatives can increase a sense of control, it may not directly address the immediate need to process and verbalize emotions to reduce anxiety.
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
- A. Encourage the patient to talk about significant childhood religious experiences.
- B. Offer to take the patient to a revival the nurse's church is holding in the community.
- C. Read to the patient Bible passages that seem particularly relevant to the patient's case.
- D. Explore what the mobility, sight, and hearing changes mean to the patient.
Correct Answer: D
Rationale: The correct answer is D because exploring the impact of the mobility, sight, and hearing changes on the patient allows the nurse to address the patient's holistic needs, including spiritual distress. By understanding the patient's perspective on these changes, the nurse can provide support tailored to the patient's concerns, fostering a sense of connection and understanding.
Choice A is incorrect because focusing solely on childhood religious experiences may not address the current issues the patient is facing. Choice B is inappropriate as it imposes the nurse's religious beliefs on the patient. Choice C is also incorrect as it assumes a specific religious approach without considering the patient's individual beliefs and needs.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
A category 5 tornado occurred in a community of 400 people. Many homes and businesses were destroye In the 2 years following the disaster, 140 individuals were diagnosed with posttraumatic stress disorder (PTSD). Which term best applies to these newly diagnosed cases?
- A. Prevalence
- B. Comorbidity
- C. Incidence
- D. Parity
Correct Answer: C
Rationale: The term that best applies to the newly diagnosed cases of PTSD is "Incidence" (Choice C). Incidence refers to the rate of new cases of a disease within a specific population over a defined period. In this case, the 140 individuals newly diagnosed with PTSD in the 2 years following the tornado represent the occurrence of new cases within the community of 400 people. This term specifically addresses the number of new cases arising from a particular event or exposure.
Summary:
A: Prevalence refers to the total number of cases (new and existing) within a population at a specific point in time.
B: Comorbidity refers to the presence of two or more conditions in an individual at the same time.
D: Parity refers to equality or equivalence, which is not relevant to the context of new PTSD diagnoses post-tornado.