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A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?
- A. The client is using manipulation to receive secondary gain.
- B. The client is using the defense mechanism of denial.
- C. The client is having trouble terminating the relationship.
- D. The client is using splitting as a way to remain dependent on the nurse.
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates denial of the upcoming change in nurses due to their belief that they are not well enough to switch. This defense mechanism helps the client avoid the reality of the situation. Choice A is incorrect as there is no evidence of manipulation for secondary gain. Choice C is incorrect as the client is not expressing difficulty in terminating the relationship. Choice D is incorrect as splitting involves seeing people as all good or all bad, which is not evident in the client's statement.
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Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
A nurse should provide this information to facilitate which ethical principle?
- A. Autonomy
- B. Beneficence
- C. Nonmaleficence
- D. Justice
Correct Answer: A
Rationale: The correct answer is A: Autonomy. Autonomy refers to respecting an individual's right to make informed decisions about their own care. Providing information empowers patients to make autonomous decisions, aligning with this principle. Beneficence focuses on doing good for the patient, nonmaleficence on avoiding harm, and justice on fairness in resource allocation. While these are important ethical principles in healthcare, they do not directly relate to the act of providing information to support patient autonomy.
An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
- A. Encourage exploration of sexual abuse
- B. Encourage guided imagery
- C. Establish trust and rapport
- D. Administer antianxiety medications
Correct Answer: C
Rationale: The correct answer is C: Establish trust and rapport. This is the priority because building a therapeutic relationship is essential for effective treatment of DID. Trust and rapport are foundational for the client to feel safe and supported in exploring and processing traumatic experiences. Encouraging exploration of sexual abuse (Option A) may be overwhelming and retraumatizing without a solid therapeutic alliance. Guided imagery (Option B) might not be appropriate at this stage as the client needs to establish trust first. Administering antianxiety medications (Option D) alone does not address the root cause or provide the necessary support for the client's complex trauma history.
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.