Nokea
During the nurse's shift in the emergency department, a nurse assesses a client who is suspected of being under the influence of opioids. Which symptom is indicative of opioid use?
- A. hypotension
- B. diaphoresis
- C. shallow respirations
- D. outbursts of anger
Correct Answer: C
Rationale: Shallow respirations are a hallmark of opioid intoxication due to respiratory depression.
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A prenatal client has been told during a primary health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client concern would this assessment data best support?
- A. Pain
- B. Nonadherence
- C. Anticipatory grieving
- D. High risk for infection
Correct Answer: C
Rationale: A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem as a result of an inability to achieve life goals. Although the remaining options may be appropriate problem statements, they do not address the information given in the question.
The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which should the nurse assess to yield the best information about this area of functioning?
- A. Judgment
- B. Emotions
- C. Consciousness
- D. Eye movements
Correct Answer: B
Rationale: Feelings and emotions are part of the role of the limbic system. Eye movements are under the control of cranial nerves III, IV, and VI. The level of consciousness is controlled by the reticular activating system. Insight, judgment, and planning are part of the function of the frontal lobe.
A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for?
- A. Stating a fear of the future and unknown
- B. Engaging in periods of weeping or raging
- C. Expressing anger at the medical professionals
- D. Expressing a feeling of unreality and disbelief
- E. Expressing a desire to run away from the situation
- F. Stating that he knows all he needs to know about his condition
Correct Answer: A,B,C,D,E
Rationale: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear.
A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
- A. Finding out your baby has a serious health problem must be painful.
- B. How does your husband feel about this problem?
- C. How is your baby doing now?
- D. What you need to do is to focus on the present.
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
A client with schizophrenia states to the nurse, 'I am a spy for the FBI. I am an eye, an eye in the sky.' Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
- A. Echolalia
- B. Word salad
- C. Clang associations
- D. Loosened associations
Correct Answer: C
Rationale: The repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern seen in clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another. Loosened associations occur when the individual speaks with frequent changes of subject and when the content is only obliquely related.