Nokea
A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.
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The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?
- A. The client is experiencing delusions of messianic grandeur.
- B. The client believes that the world is ending on a specific date.
- C. The client is experiencing persistent pain after the resolution of herpes zoster.
- D. The client is experiencing blindness without an identified physical cause.
Correct Answer: D
Rationale: Conversion disorder involves physical symptoms, like blindness, without a medical cause, often linked to psychological stress. Blindness without a physical cause is a classic example, unlike delusions or unrelated pain.
An 11-year-old child scheduled for a diagnostic procedure will have an intravenous line inserted and will receive an intramuscular injection. Which form of communication should the nurse use in preparing the child for the procedure?
- A. Reassuring the child by introducing the equipment used
- B. Teaching the parents so that they can explain everything to the child
- C. Telling the child not to worry because the doctors take care of everything
- D. Using pictures, concrete words, and demonstrations to describe what will happen
Correct Answer: D
Rationale: Using pictures, concrete words, and demonstrations is the most effective way to communicate with an 11-year-old child about a medical procedure, as it aligns with their developmental stage and helps them understand what to expect. Option 1 may not fully address the child's need for clear explanations. Option 2 relies on parents, which may not be as direct or effective. Option 3 dismisses the child's concerns and is nontherapeutic.
A client diagnosed with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse should make which interpretation about this behavior?
- A. The client is depressed.
- B. The client is noncompliant.
- C. The client has intractable pain.
- D. The client is unable to tolerate activity.
Correct Answer: A
Rationale: Depression is a common problem related to clients who have long-term and debilitating illnesses. None of the remaining options are related to the symptoms present in the question and therefore are not appropriate interpretations.
A client is suspected of having posttraumatic stress disorder. Which problem is the most important for the nurse to assess?
- A. panic attacks
- B. anorexia
- C. suicide
- D. short-term memory loss
Correct Answer: C
Rationale: Suicide risk is the most critical to assess in PTSD due to high rates of suicidal ideation and attempts.
The nurse on the cardiac unit notes that a client recovering from a myocardial infarction appears worried and irritable. The client says, 'I am worried about my business. I run a restaurant and am used to working 70 hours a week. I am worried about whether I will be able to handle the stress once I am back there.' Which response by the nurse is best?
- A. Give the client a list of complementary therapies related to relaxation and say, 'Pretend this is a menu. Which of these would you like to order for yourself?'
- B. You might find it interesting to attend the cardiac cooking class the dietitian gives before you are discharged.
- C. Who is supposed to be taking care of the restaurant while you are here in the hospital?
- D. Hand the client the television control and say, 'Sometimes when I have a lot on my mind, I watch a movie. It makes me feel better.'
Correct Answer: A
Rationale: Providing a list of relaxation therapies directly addresses the client’s stress concerns and empowers them to choose coping strategies, aligning with their expressed worries about returning to a high-stress job. Other options are less relevant to stress management.