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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. Choice 1 is an open and candid response but diminishes the client's self-esteem. Choice 2 doesn't answer the client's question and is not helpful. Choice 3 increases the client's anxiety because her inability to walk might be directly related to an unconscious psychological conflict that has not been resolved.
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A batterer is usually someone who:
- A. grew up in a loving, secure home.
- B. was an only child.
- C. was physically or psychologically abused.
- D. admits he has a problem with anger.
Correct Answer: C
Rationale: Many batterers report having been abused as children.
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: Denial (Kübler-Ross's Stages of Grieving) is the refusal to believe that loss is happening.
A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?
- A. voiding patterns
- B. characteristics of lesions
- C. vaginal discharge
- D. prior history of varicella
Correct Answer: D
Rationale: The other choices are common reasons for which clients with herpes seek care.
What significant event occurs in the orientation phase of a nurse-client relationship?
- A. establishment of roles
- B. identification of transference phenomenon
- C. placement of the client within the client's family structure
- D. client agreement that the nurse has the authority in the relationship
Correct Answer: B
Rationale: Transference phenomena are intensified in relationships with authority, such as physicians and nurses. Common positive transferences include desire for affection and gratification of dependency needs. Common negative transferences include hostility and competitiveness. These transferences must be recognized and resolved before growth and positive change can be undertaken in the working stage.
A client is 36 hours post-op a TKR surgery, 270 cc's of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
- A. Notify the doctor
- B. Empty the drain
- C. Do nothing
- D. Remove the drain
Correct Answer: A
Rationale: The physician should be notified if excessive drainage is noted from the surgical site.