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A nurse is speaking with the parents of a 4-year-old child who has a terminal illness. The parents tell the nurse they have taken their son's name off the list for little league baseball next season. Which of the following responses should the nurse make?
- A. It must be frustrating for you to have to cancel an activity your son enjoyed.'
- B. Baseball can be a dangerous sport for children anyway.'
- C. You never know. He could be ready for baseball by the spring.'
- D. Why did you feel you needed to do that at this time?'
Correct Answer: A
Rationale: The correct answer is A: "It must be frustrating for you to have to cancel an activity your son enjoyed." This response shows empathy and acknowledges the parents' feelings without judgment. It validates their emotions and demonstrates understanding of their situation. Choice B is incorrect because it is dismissive and irrelevant to the parents' emotional state. Choice C is incorrect as it minimizes the parents' decision and disregards their current feelings. Choice D is incorrect as it may come off as confrontational and not empathetic towards the parents' emotions. The key is to show empathy and understanding towards the parents' situation, making choice A the most appropriate response.
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How should a nurse address compulsive behaviors in a newly admitted client with OCD?
- A. Isolate the client
- B. Confront the client about the behavior
- C. Encourage participation in group activities
- D. Set strict limits on behaviors
- E. Allow additional time for rituals
Correct Answer: D
Rationale: Correct Answer: D. Set strict limits on behaviors
Rationale:
1. Setting strict limits helps establish boundaries and structure for the client.
2. It assists in reducing compulsive behaviors by providing clear guidelines.
3. It promotes a sense of control and safety for the client.
4. Allows for gradual exposure and response prevention therapy.
Summary:
A: Isolating the client can exacerbate feelings of loneliness and increase anxiety.
B: Confrontation may trigger defensiveness and hinder therapeutic rapport.
C: While group activities can be beneficial, they may not directly address the compulsive behaviors.
E: Allowing additional time for rituals reinforces maladaptive behaviors.
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
- A. Vitamin deficiency
- B. Diaphoresis
- C. Tremors
- D. Visual hallucinations
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice A), diaphoresis (choice B), and tremors (choice C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations. Therefore, addressing visual hallucinations takes priority over these symptoms.
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
- A. Nystagmus
- B. Dilated pupils
- C. Hypersomnia
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. Cocaine intoxication typically presents with dilated pupils due to the drug's stimulant effects on the sympathetic nervous system. This causes pupil dilation by increasing the release of norepinephrine. Nystagmus (choice A) is not a common finding in cocaine intoxication. Hypersomnia (choice C) is unlikely as cocaine is a stimulant that often leads to decreased need for sleep. Depression (choice D) is not a typical symptom of cocaine intoxication. In summary, dilated pupils are a key indicator of cocaine intoxication, while nystagmus, hypersomnia, and depression are not characteristic findings.
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.