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A client reports hearing voices. What should the nurse do next?
- A. Touch the client to help him return to reality.
- B. Leave the client alone until reality returns.
- C. Ask the client to describe what is happening.
- D. Tell the client there are no voices.
Correct Answer: C
Rationale: When a client reports hearing voices, it might indicate hallucinations. It is essential for the nurse to ask the client to describe what is happening to gain a better understanding of the hallucinations. This approach helps in assessing the severity and content of the hallucinations, which can guide further interventions. Touching the client without consent can be intrusive and may escalate the situation, violating the client's personal space. Leaving the client alone may not address the underlying issue of hallucinations and can lead to potential risks if the client is distressed. Telling the client there are no voices denies their experience, invalidates their feelings, and can result in mistrust between the client and the nurse.
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During the work phase of the nurse-client relationship, the client says to her primary nurse, "You think that I could walk if I wanted to, don't you?"? What is the best response by the nurse?
- A. "Yes, if you really wanted to, you could."?
- B. "Tell me why you're concerned about what I think."?
- C. "Do you think you could walk if you wanted to?"?
- D. "I think you're unable to walk now, whatever the cause."?
Correct Answer: D
Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client's self-esteem. The nurse acknowledges the client's current inability to walk without attributing it to the client's desire. Choice A provides a positive but unrealistic statement that may diminish the client's self-esteem by implying a lack of effort. Choice B deflects the client's question and does not address the underlying concern. Choice C may increase the client's anxiety by suggesting unresolved psychological conflicts related to walking.
The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
- A. elevated blood pressure.
- B. Cheyne-Stokes respiration.
- C. elevated pulse rate.
- D. decreased temperature.
Correct Answer: B
Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.
Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice B, crisis intervention, is the correct answer. Counseling by a nurse specialist in a rape crisis situation is a form of crisis intervention, which is part of the Crisis Intervention Model. It aims to provide immediate support and help the victim cope with the traumatic event. Empathetic concern (Choice C) is important but refers more to the nurse's attitude rather than the specific action described. Assessment (Choice A) typically involves gathering information and may have already been done before counseling. Unwarranted intrusion (Choice D) is not applicable here as the counseling is provided to support the victim in a professional and caring manner.
A two-year-old has been in the hospital for 3 weeks and has seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?
- A. Guilt
- B. Trust
- C. Separation anxiety
- D. Shame
Correct Answer: C
Rationale: The correct answer is 'Separation anxiety.' Separation anxiety is a common response in young children when they are separated from their primary caregivers for extended periods. In this case, the two-year-old being in the hospital for three weeks and not being able to see family members due to isolation precautions can trigger separation anxiety. 'Guilt' is a feeling of responsibility for wrongdoing, which is not the most likely change occurring in this scenario. 'Trust' involves reliance and confidence in others, not typically associated with prolonged separation from family. 'Shame' is a negative emotion related to feeling disgrace, which is not the most appropriate response in this hospitalization situation.
If the nurse who was not promoted tells another friend, "I knew I'd never get the job. The hospital administrator hates me."? If she actually believes this of the administrator, who, in reality, knows little of her, she is demonstrating:
- A. compensation.
- B. reaction formation.
- C. projection.
- D. denial.
Correct Answer: C
Rationale: The nurse is demonstrating projection, attributing her own feelings of dislike onto the hospital administrator. This defense mechanism involves unconsciously adopting blaming behavior. Compensation involves emphasizing a strong point to make up for a perceived weakness, which is not the case here. Reaction formation is adopting behavior opposite to actual feelings, and denial involves ignoring an unpleasant reality, none of which are demonstrated in this scenario.