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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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The most effective nursing strategy to assist a client in recognizing and using personal strength includes:
- A. encouraging the client's self-identification of strengths
- B. promoting the client's active external thinking
- C. listening to the client and providing advice as needed
- D. assisting the client in maintaining an external locus of control
Correct Answer: A
Rationale: Encouraging self-identification of strengths empowers the client to recognize their capabilities, fostering confidence and resilience. External thinking or locus of control may disempower, and advice-giving is less effective than self-discovery.
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.
Incidences of child abuse appear to be higher in the African-American community and might be explained by:
- A. The increased number of African Americans viewing violence on television
- B. More single-parent households in African-American communities
- C. Stricter child-rearing practices in African-American households
- D. A higher occurrence of rage in African Americans
Correct Answer: B
Rationale: Higher child abuse rates in African-American communities correlate with socioeconomic stress and single-parent households, not violence exposure, strict practices, or inherent rage.
In alcoholics with anemia:
- A. pernicious anemia is more common than folic acid deficiency.
- B. iron deficiency and folic acid deficiency can coexist.
- C. the alcohol interferes with iron absorption.
- D. oral vitamin replacement is contraindicated.
Correct Answer: B
Rationale: The ingestion of nonfood substances (alcohol) can lead to a clinical iron deficiency and might actually be the first sign of a problem. The client might substitute alcohol for a nutrition program that fosters a positive health habit.
Legal protection of confidentiality:
- A. extends only to written documentation.
- B. extends to the electronic dissemination of information not identifiable to a specific client.
- C. is important only within the court system.
- D. extends to both written and verbal information.
Correct Answer: D
Rationale: Legal protection of confidentiality extends to both written and verbal information identifiable as individual private health information.