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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.
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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.
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 patient whose history includes experiences with abusive partners is being treated for major depressive disorder. The patient's care plan includes rape-trauma syndrome among its nursing diagnoses. What goal is directly associated with this diagnosis?
- A. Remains free from self-harm
- B. Wears appropriate clothing
- C. Reports feeling stronger and having a sense of hopefulness
- D. Demonstrates appropriate affect for both positive and negative emotions
Correct Answer: C
Rationale: The correct answer is C: Reports feeling stronger and having a sense of hopefulness. This goal is directly associated with rape-trauma syndrome as it focuses on the patient's emotional healing and empowerment. By reporting feeling stronger and having hope, the patient is demonstrating progress towards recovery from the trauma. Choice A is incorrect because remaining free from self-harm is more related to monitoring safety rather than addressing the emotional impact of the trauma. Choice B is irrelevant as wearing appropriate clothing does not directly address the emotional healing process. Choice D is incorrect as demonstrating appropriate affect does not specifically target the psychological aspect of overcoming trauma.
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.
A client on a psychiatric unit says,"It's a waste of time to be here. I can't talk to you or anyone." Which would be an appropriate therapeutic nursing response?
- A. "I find that hard to believe."
- B. "Are you feeling that no one understands?"
- C. "I think you should calm down and look on the positive side."
- D. "Our staff here is excellent, and you are in good hands."
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and encourages the client to express their feelings. By asking if the client feels that no one understands, the nurse acknowledges the client's emotions and opens the door for further discussion. Choice A is confrontational and may make the client defensive. Choice C dismisses the client's feelings and is not validating. Choice D is a vague reassurance that does not address the client's concerns.