Nokea
A preschooler has just been diagnosed with impetigo. The child's mother tells the nurse, 'But my children take baths every day.' Which therapeutic response should the nurse make to the mother?
- A. You are concerned about how your child got impetigo?'
- B. There is no need to worry. We will not tell your day care provider why your child is absent.'
- C. Not only do you have to do a better job of keeping your children clean, you must also wash your hands more frequently.'
- D. You should have seen the doctor before the wound became infected, and then you would not have had to worry about the child having impetigo.'
Correct Answer: A
Rationale: By paraphrasing what the parent tells the nurse, the nurse is addressing the parent's thoughts. Option 1 demonstrates the therapeutic technique of paraphrasing. The remaining options are blocks to communication because they make the parent feel guilty for the child's illness.
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A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which should the nurse plan to include as part of one of these discussions?
- A. Ongoing fluid restriction
- B. The need for genetic counseling
- C. The risk of hypotensive episodes
- D. Depression regarding massive edema
Correct Answer: B
Rationale: Adult polycystic kidney disease is a hereditary disorder that is inherited as an autosomal-dominant trait. Because of this, the client and the extended family should have genetic counseling. Ongoing fluid restriction is unnecessary. The client is likely to have hypertension rather than hypotension. Massive edema is not part of the clinical picture of this disorder.
While providing care to a 12-year-old client, the nurse observes small round burn scars on the client's arms and legs, bruising on the buttocks, and tenderness of the right jaw. The client is anxious, has poor eye contact, and denies being injured at home when the nurse asks questions. Based on these observations, the nurse suspects victimization. Which is the next priority question the nurse should therapeutically ask the client in providing a safe environment for the client?
- A. Are you sure your parents didn't do this?
- B. You need to tell me now, or I'll call security, who did this to you?
- C. Is someone bullying you at school, or at home, or in your neighborhood?
- D. I can see this is difficult for you to talk about, you are safe here, but I need to ask you, who hurt you like this?
Correct Answer: D
Rationale: Based on the nurse's assessment data, the suspect of victimization needs to be analyzed to determine how the client received the old and new injuries. Option 4 offers the therapeutic approach for obtaining information using an open-ended question. It is important to determine if the injuries resulted from a family member or someone else outside the home. There are many forms of abuse besides physical abuse to consider such as sexual, emotional, and psychological abuse. Identifying the victimizer is important to stop the abuse and avoid further injuries. Safety is a priority concern for the client while in the care of the nurse and then after discharge from care. Option 1 implies that the nurse is challenging if the client is telling the truth. Option 2 could be perceived as demanding and a threat to the client to answer the question. Option 3 focuses on outside the family but there is not enough information given in the question to determine whether a family member is not suspected.
The nurse is caring for a client diagnosed with left-sided Bell's palsy. Which statement by the client shows a need for further teaching by the nurse?
- A. My left eye is tearing a lot.'
- B. I have trouble closing my left eyelid.'
- C. I don't know how I'll live with this stroke.'
- D. I can't feel anything on the left side of my face.'
Correct Answer: C
Rationale: Bell's palsy is an inflammatory condition that involves the facial nerve (cranial nerve VII). Although it results in facial paralysis, it is not the same as a stroke. Many clients fear that they have had a stroke when the symptoms of Bell's palsy appear, and they commonly believe that the paralysis is permanent. Symptoms resolve, although it may take several weeks. The remaining options are expected assessment findings of the client with Bell's palsy.
A primigravida client who came to the clinic has been diagnosed with a urinary tract infection. She repeatedly verbalizes concern regarding the safety of the fetus. Which should the nurse address first?
- A. Maternal and infant safety
- B. Obtaining a sedative prescription
- C. Instructions regarding improved hygiene
- D. Instructions regarding medication compliance
Correct Answer: A
Rationale: The primary concern of this client is the safety of her fetus rather than herself. The priority for the nurse to address at this time is the issues regarding safety. The remaining options lack this priority.
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.