Nokea
In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:
- A. Accepting the denial.
- B. Supporting the denial.
- C. Confronting the denial.
- D. Interpreting the denial.
Correct Answer: C
Rationale: Confronting the denial is the best response in this situation. Denial is a common defense mechanism that individuals may use when faced with overwhelming emotions or situations, such as in the case of a post-mastectomy client. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and accept their feelings, which is an important step in the healing and coping process. Ignoring or supporting the denial may hinder the client's ability to address their emotions and work through them effectively. Confronting the denial allows for open communication and helps the client move towards acceptance and adjustment.
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Minda, a 65-year old female has been admitted with a left hemisphere stroke. Which behavioral change would the nurse expect to find upon assessment?
- A. impulsive, unsafe activity
- B. motor deficits on the right eye
- C. motor deficits on the left side of the body
- D. error in word choices
Correct Answer: D
Rationale: A left hemisphere stroke typically affects the right side of the body due to the way the brain controls motor functions. Since the left hemisphere is also responsible for language and speech processing, patients with a left hemisphere stroke commonly exhibit errors in word choices, difficulty speaking or understanding language, aphasia, and other language-related impairments. This is known as Broca's aphasia or expressive aphasia. Therefore, the nurse would expect to find errors in word choices as a behavioral change in a patient like Minda with a left hemisphere stroke.
Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The main reason why older clients with AIDS need more care than their younger counterparts is because older clients have a faster progression of the disease. As a person ages, their immune system tends to weaken, making them more vulnerable to infections and complications from diseases like AIDS. Older individuals may have decreased immune function and lower resilience when combating HIV-related complications compared to younger clients. This faster disease progression necessitates more frequent monitoring, specialized care, and management strategies tailored to the specific needs of older patients with AIDS. Therefore, older clients with AIDS require more support, medical attention, and comprehensive care to address their complex health needs effectively.
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: Keeping the extremities at a neutral position for a client with a neurologic disorder can help reduce hemostasis and decrease the potential for thrombophlebitis. This positioning helps maintain proper blood flow and prevents excessive pressure on the veins, which can lead to blood clots. Removing and reapplying elastic stockings, changing the client's position, and using a flotation mattress may have their own benefits, but in this case, keeping the extremities at a neutral position is the most direct and effective intervention to address the issue of hemostasis and thrombophlebitis for a client with a neurologic disorder.
A 9-mo-old infant is recently diagnosed with bilateral retinoblastoma; examination under anesthesia reveals bilateral multifocal involvement of the retina. An important next step in the management is
- A. radiotherapy of both eyes
- B. retinal examination of 1st degree relatives
- C. orbital ultrasonography
- D. bilateral enucleation
Correct Answer: B
Rationale: Retinal examination of first-degree relatives is crucial to identify hereditary forms of retinoblastoma.
Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?
- A. My child is able to stand but is not yet taking steps independently.
- B. My child has a vocabulary of approximately 15 words.
- C. My child is still sucking his thumb.
- D. My child seems to be quite wary of strangers.
Correct Answer: A
Rationale: By 15 to 18 months, most toddlers should be walking independently. An 18-month-old who is not yet walking warrants further evaluation.