Nokea
A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
- A. Injury to the fetus because of maternal distress
- B. Low self-esteem because of pregnancy complications
- C. Lack of understanding about diabetic self-care during pregnancy
- D. Poorly perceived body image caused by complications of pregnancy
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
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The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern?
- A. Lack of knowledge about COPD
- B. Difficulty coping related with a situational crisis
- C. Negative self-image because of neurological deficit
- D. Restricted verbal communication because of a physical barrier
Correct Answer: D
Rationale: A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options.
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.
The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, 'Get it yourself!' The nurse recognizes the charge nurse is displaying which defense mechanism?
- A. Compensation.
- B. Displacement.
- C. Conversion.
- D. Projection.
Correct Answer: B
Rationale: Displacement involves redirecting emotions from one target to another. The charge nurse, upset from the reprimand, displaces anger onto the client by responding harshly to a simple request, rather than addressing the supervisor.
While assisting with bathing, the client who has sustained a spinal cord injury states, 'I can't do this. I wish I were dead.' Which therapeutic response should the nurse make to encourage communication?
- A. Why do you say that?
- B. You wish you were dead?
- C. Would you prefer a shower instead?
- D. Are you frustrated with your limitations?
Correct Answer: B
Rationale: Clarifying is a therapeutic technique that involves restating what was said to obtain additional information. By asking 'why' in option 1, the nurse puts the client on the defensive. Option 3 changes the subject. In option 4, false reassurance is offered. The remaining options are nontherapeutic statements that block communication.
A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for?
- A. Stating a fear of the future and unknown
- B. Engaging in periods of weeping or raging
- C. Expressing anger at the medical professionals
- D. Expressing a feeling of unreality and disbelief
- E. Expressing a desire to run away from the situation
- F. Stating that he knows all he needs to know about his condition
Correct Answer: A,B,C,D,E
Rationale: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.