Nokea
A preschool child is placed in traction for a femur fracture. The child has started bedwetting, even though the child has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation?
- A. A body image disturbance
- B. Attention-seeking behavior
- C. Opposition to authority figures
- D. Regressing to earlier developmental behavior
Correct Answer: D
Rationale: The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children, and they usually do not require professional intervention. Body image may or may not be affected by long-term immobilization, but it does not relate to the information presented in the question. The remaining options are not relevant to the described situation.
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The nurse is preparing a plan of care for a client demonstrating mania. Which interventions should be included in the plan of care?
- A. Place the client in seclusion.
- B. Ignore any client complaints.
- C. Use a firm and calm approach.
- D. Use short and concise explanations and statements.
- E. Remain neutral and avoid power struggles and value judgments.
- F. Firmly redirect energy into more appropriate and constructive channels.
Correct Answer: C,D,E,F
Rationale: A client with mania will be extremely restless, disorganized, and chaotic. Grandiose plans are extremely out of touch with reality, and judgment is poor. Interventions for the client in acute mania include using a firm and calm approach to provide structure and control, using short and concise explanations or statements because of the client's short attention span, remaining neutral and avoiding power struggles and value judgments, being consistent in approach and expectations and having frequent staff meetings to plan consistent approaches and to set agreed-on limits to avoid manipulation by the client, hearing and acting on legitimate client complaints, and redirecting energy into more appropriate and constructive channels.
A client who is receiving total parenteral nutrition (TPN) tells the nurse, 'I'm not sure that I want to receive an infusion of lipids because it could make me obese.' Which initial action should the nurse take?
- A. Inquire how illness affects the client's self-concept.
- B. Ask the provider to discuss the benefits of intralipids.
- C. State that intralipids supply essential fatty acids for life.
- D. Explain how intralipids replace dietary sources of lipids.
Correct Answer: A
Rationale: A client who receives TPN is at risk for developing an essential fatty acid deficiency; however, this client's comment requires more than a simple informational response initially. Thus, the nurse responds with option 1 to assist the client with self-expression and to deal with aspects of illness and treatment. Option 2 delays client self-expression and devalues the client's feelings. Options 3 and 4 provide information only.
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
- A. Risk of tachycardia
- B. Probability of fatigue
- C. High incidence of hypoglycemia
- D. Possible exacerbation of depression
Correct Answer: D
Rationale: Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia rather than tachycardia. Fatigue is a possible side effect, but it is not the most important item. Hypoglycemia is a sign that is masked with beta blockers.
While in the dining area, an adult client at the retirement center yells, 'This turkey is dry and cold! I can't stand the food here!' Which is the best response by the nurse to the client's behavior?
- A. Now look what you've done! You're ruining this meal for the whole community. Aren't you ashamed of yourself?
- B. I think you had better return to your apartment now. I'll make arrangements for a new meal to be served to you there.
- C. Let me get you another serving that is more to your liking. Would you like to see the chef and select your own serving?
- D. One of the things that was agreed upon was that anyone who did not use appropriate behavior would be asked to leave the dining room. Please leave now.
Correct Answer: C
Rationale: Asking the client to accompany the nurse to the kitchen respects the client's need for control, removes the angry client from the dining room, and may offer the nurse an opportunity to assess what is happening with the client. Agency procedure should be followed regarding those who are allowed access to the facility kitchen. Option 1 is angry, aggressive, and nontherapeutic. Option 2 could provoke a regressive struggle between the nurse and the client and cause more anger in the client. In option 4, the nurse is authoritative, and it would not be appropriate to ask the client to leave. This action may set up an aggressive struggle between the nurse and the client.
A client who is to be discharged to home with a temporary colostomy states to the nurse, 'I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?' Which therapeutic response should the nurse make to best deal with the client's concerns?
- A. This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery.'
- B. So you're saying that, although you've practiced changing your colostomy bag once, you don't feel comfortable on your own yet?'
- C. Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you'll have to fight it out with them.'
- D. Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable.'
Correct Answer: D
Rationale: The client is expressing feelings of fear and helplessness. Option 4 assists with meeting this client's needs. Option 1 provides information that the client already knows and then problem-solves by using a client-centered action, which would probably overwhelm the client. Option 2 is restating, but this response could cause the client to feel more helpless because the client's fears are reflected back to the client. Option 3 provides what is probably accurate information, but the words 'just to practice' can be interpreted by the client as belittling.