Nokea
A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
- A. prosecuting the perpetrator
- B. managing symptoms of anxiety and fear
- C. determining if the memories are real
- D. collaborating the client's story
Correct Answer: B
Rationale: The nurse's role is to help the client deal with the stress caused by the remembered abuse.
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James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial.
- B. suppression.
- C. displacement.
- D. fantasy.
Correct Answer: C
Rationale: Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object.
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 nurse is assessing a patient's breath sounds. The patient has had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
- A. Decreased breath sound volume
- B. Elevated tidal volume
- C. Elevated respiratory capacity
- D. Wheezing
Correct Answer: A
Rationale: Breath sounds would be softer due to the removal of the right lung, reducing the area available for air exchange.
A client is assessed by the nurse as experiencing a crisis. The nurse plans to:
- A. allow the client to work through independent problem-solving.
- B. complete an in-depth evaluation of stressors and responses to the situation.
- C. focus on immediate stress reduction.
- D. recommend ongoing therapy.
Correct Answer: C
Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from a situational, developmental, or societal source of stress. Utilizing the nursing process, the nurse should assist clients to work through a crisis to its resolution and restore their precrisis level of functioning.
Nursing considerations when caring for African-American clients include that:
- A. families are generally distant and unsupportive
- B. special hair, skin, and nail care might be required
- C. fad diets are a cultural norm
- D. clients are generally future-oriented
Correct Answer: B
Rationale: African-American clients may require specific hair, skin, and nail care due to unique characteristics like tightly coiled hair or higher risk of keloid scarring. The other options are stereotypes or incorrect: families are often supportive, fad diets are not a cultural norm, and future orientation is not a defining trait.