Nokea
A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic selfexpectations) is when the client can:
- A. report a positive self-concept.
- B. identify negative thoughts.
- C. recognize positive thoughts.
- D. give one positive cue with each negative cue.
Correct Answer: A
Rationale: The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.
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Which of the following describes the stages of domestic violence in an intimate relationship?
- A. Happiness, crisis, angry outburst, intervention
- B. Honeymoon period, escalation of stress, outburst, reconciliation
- C. Acting out and making up
- D. Peace and calm, angry outburst, peace and calm, denial
Correct Answer: B
Rationale: The cycle of abuse includes a honeymoon phase, stress escalation, an outburst (often violent), and reconciliation, increasing the risk of harm if unaddressed.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.
The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this the nurse should:
- A. tell the client to stop using the defense mechanism of denial.
- B. positively reinforce each expression of feelings.
- C. instruct the client to express feelings.
- D. challenge the client each time denial is used.
Correct Answer: B
Rationale: The nurse should positively reinforce each expression of feelings.
A 24 year-old man has been admitted to the hospital due to work-related back injury. The patient's wife would like to see the patient's chart. The nurse should:
- A. Provide the chart to the patient's wife following verbal approval by the patient.
- B. Provide the chart to the patient's wife after consulting with the patient's physician.
- C. Get written approval from the patient prior to providing the wife with chart information and call the MD about the patient's request.
- D. Tell the patient's wife, a copy of the patient's medical record is on-file with medical records.
Correct Answer: C
Rationale: Some facilities require the physician to be notified about a patient's request and written permission from the husband is required for the wife to view the chart.
A two-year old has been in the hospital for 3 weeks and 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: Separation anxiety can easily occur after six months during hospitalization.