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A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?
- A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
- B. Encourage the client to seek genetic counseling to determine his risk for mental illness.
- C. Inform the client that his mother's schizophrenia has affected his psychological development.
- D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct Answer: B
Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.
A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Anxiety related to treatment plan
- B. Deficient knowledge of lifestyle changes
- C. Ineffective coping related to denial
- D. Decisional conflict due to stress
Correct Answer: C
Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out." The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Splitting
- C. Projection
- D. Rationalization
Correct Answer: C
Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.
Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these findings, what is the client's greatest risk?
- A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
- B. Neurovascular and circulation compromise related to compartment syndrome.
- C. Wound infection and delayed healing due to fractured bone protrusion.
- D. Venous stasis and thrombophlebitis related to postoperative immobility.
Correct Answer: B
Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.
An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions clearly. What action should the nurse implement first?
- A. Assess the surroundings for noise and distractions
- B. Provide a printed health history form
- C. Defer the health history until the client is less anxious
- D. Ask the family member to answer the questions
Correct Answer: A
Rationale: The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.