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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 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.
A twenty-eight-year-old client enters the family therapy meeting clutching a blanket and holds the blanket throughout the session while rocking back and forth in the chair. What defense mechanism is the client demonstrating?
- A. denial
- B. projection
- C. undoing
- D. regression
Correct Answer: D
Rationale: The correct answer is D: regression. The client clutching a blanket and rocking back and forth indicate a return to an earlier stage of development to cope with stress or anxiety. Regression involves reverting to behaviors from a less mature stage. Denial (A) involves refusing to acknowledge reality, projection (B) involves attributing one's feelings onto others, and undoing (C) involves trying to undo or reverse an unacceptable action or thought. These defense mechanisms do not align with the client's behavior of regression.
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.
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.
The statement"Growth involves resolution of critical tasks through the eight stages of the life cycle" is a concept of which therapeutic model?
- A. Interpersonal.
- B. Cognitive-behavioral.
- C. Intrapersonal.
- D. Psychoanalytic.
Correct Answer: A
Rationale: The correct answer is A: Interpersonal. This concept aligns with Erikson's psychosocial theory, which emphasizes the importance of resolving developmental tasks at each stage of life. Interpersonal therapy focuses on relationships and interactions with others, making it the most suitable model for addressing growth through the life cycle. Choice B (Cognitive-behavioral) focuses on thoughts and behaviors, not developmental stages. Choice C (Intrapersonal) refers to self-awareness and understanding, not specifically addressing life stages. Choice D (Psychoanalytic) focuses on unconscious processes and early childhood experiences, not necessarily on resolving tasks through different life stages.