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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.
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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 nursing student is assigned to care for a patient diagnosed with schizophrenia. When talking about this patient in a clinical postconference, the student would use which terminology when referring to the patient?
- A. Committed patient
- B. Schizophrenic
- C. Schizophrenic patient
- D. Person with schizophrenia
Correct Answer: D
Rationale: The correct answer is D: Person with schizophrenia. This terminology aligns with person-first language, which emphasizes the individuality and humanity of the patient over their diagnosis. It is important to use person-first language to promote respect and reduce stigma. Using terms like "committed patient" (A) can be stigmatizing and inaccurate, as not all patients with schizophrenia are committed involuntarily. "Schizophrenic" (B) and "schizophrenic patient" (C) both label the individual by their diagnosis, which can be dehumanizing and reduce their identity to just their condition. In contrast, "person with schizophrenia" (D) acknowledges the personhood of the individual first and foremost.
Which individual is demonstrating the highest level of resilience?
- A. Is able to repress stressors.
- B. Becomes depressed after the death of a spouse.
- C. Lives in a shelter for 2 years after the home is destroyed by fire.
- D. Takes a temporary job to maintain financial stability after loss of a permanent job.
Correct Answer: D
Rationale: The correct answer is D because the individual demonstrates resilience by adapting to adversity and taking proactive steps to maintain financial stability after a setback. This shows a positive coping mechanism and ability to bounce back.
A is incorrect as repressing stressors is not a healthy way of dealing with challenges. B is incorrect as becoming depressed indicates a lack of resilience. C, although a challenging situation, does not necessarily indicate the highest level of resilience as the individual is not actively taking steps to improve their situation.
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.
As a nurse working in obstetrics, what is one way to mitigate possible causes of intellectual disability?
- A. Explain to the parent the treatment options available.
- B. Explain to the parent environmental risks to avoid during pregnancy.
- C. Explain to the parent that genetics have a role in this disability.
- D. Explain to the parent that learning disabilities often go unnoticed until the child enters school.
Correct Answer: B
Rationale: The correct answer is B because avoiding environmental risks during pregnancy can help mitigate possible causes of intellectual disability. Environmental factors such as exposure to toxins, infections, and poor nutrition can have a significant impact on fetal brain development. By educating parents about these risks, nurses can empower them to make informed choices to protect their baby's cognitive development.
Choice A is incorrect because treatment options are not preventive measures to avoid intellectual disability.
Choice C is incorrect because while genetics can play a role in intellectual disability, it is not something parents can actively mitigate during pregnancy.
Choice D is incorrect because learning disabilities are different from intellectual disabilities, and addressing them at school age is not a preventive measure during pregnancy.