Nokea
Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
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To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
- A. Encourage clients to request their medications at the appropriate times.
- B. Refuse to administer medications unless clients request them at the appropriate times.
- C. Allow the clients to determine appropriate medication times.
- D. Take medications to the clients bedside at the appropriate times.
Correct Answer: A
Rationale: The correct answer is A because it promotes self-reliance by empowering clients to take responsibility for their own medication schedule. By encouraging clients to request their medications at the appropriate times, the nurse fosters autonomy and self-management.
Choice B is incorrect as it is too extreme and may compromise client safety by withholding medications based solely on client request. Choice C is incorrect as it puts the responsibility solely on the client without appropriate guidance from the nurse. Choice D is incorrect as it does not actively involve the client in the medication administration process.
A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this clients crisis?
- A. The client will change his or her type A personality traits to more adaptive ones by week
- B. The client will completely eliminate all anxiety within 2 weeks.
- C. The client will reduce work hours from 12 to 6 hours per day immediately.
- D. The client will develop and implement a self-care routine to improve sleep and appetite within 4 weeks.
Correct Answer: D
Rationale: The correct answer is D. Developing and implementing a self-care routine to improve sleep and appetite within 4 weeks is the most realistic long-term outcome in addressing the client's crisis.
Rationale:
1. Self-care routines can positively impact sleep and appetite.
2. Improvements in sleep and appetite can help alleviate fatigue and other symptoms.
3. Realistic timeline of 4 weeks allows for gradual changes and adjustments.
4. It focuses on tangible actions the client can take to improve their well-being.
Incorrect Choices:
A: Changing personality traits is a complex and long-term process, unlikely to occur within a week.
B: Completely eliminating anxiety within 2 weeks is unrealistic and may not address the underlying causes.
C: Immediate reduction of work hours may not be feasible or necessary for addressing the client's crisis.
A nurse directs the client interaction and plans for interventions to achieve client goals. According to Peplaus framework for psychodynamic nursing, what therapeutic role is this nurse assuming?
- A. The role of technical expert
- B. The role of resource person
- C. The role of teacher
- D. The role of leader
Correct Answer: D
Rationale: The correct answer is D: The role of leader. In Peplau's framework, the nurse in this scenario is assuming the therapeutic role of a leader because they are directing client interactions and planning interventions to achieve client goals. This role involves guiding and facilitating the therapeutic process, fostering a collaborative relationship with the client, and empowering them to make decisions and progress towards their goals.
A: The role of technical expert is incorrect because it focuses more on providing specialized knowledge and skills rather than leading and directing client interactions.
B: The role of resource person is incorrect as it typically involves providing information and support, but not necessarily directing client interactions and planning interventions.
C: The role of teacher is incorrect because while education and guidance are important in nursing, it does not fully capture the leadership and direction involved in the scenario described.
A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?
- A. The client is using manipulation to receive secondary gain.
- B. The client is using the defense mechanism of denial.
- C. The client is having trouble terminating the relationship.
- D. The client is using splitting as a way to remain dependent on the nurse.
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates denial of the upcoming change in nurses due to their belief that they are not well enough to switch. This defense mechanism helps the client avoid the reality of the situation. Choice A is incorrect as there is no evidence of manipulation for secondary gain. Choice C is incorrect as the client is not expressing difficulty in terminating the relationship. Choice D is incorrect as splitting involves seeing people as all good or all bad, which is not evident in the client's statement.
A female nurse is caring for a traditional Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? Select all that apply.
- A. Limited touch is acceptable only between members of the same sex.
- B. Conversing individuals of this culture stand far apart and do not make eye contact.
- C. Devout Muslim men may not shake hands with women.
- D. The man is the head of the household and women take on a subordinate role.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. In traditional Arab American culture, limited touch is acceptable only between members of the same sex due to modesty and respect for personal boundaries.
2. This cultural consideration is important for the nurse to provide appropriate care that respects the client's cultural beliefs and preferences.
3. Understanding this aspect helps the nurse establish trust and build rapport with the male client while upholding cultural sensitivity and respect.
Summary:
- Choice B is incorrect as Arab American individuals may stand close and make eye contact during conversations.
- Choice C is incorrect as devout Muslim men may opt for not shaking hands with women due to religious beliefs, not solely based on gender.
- Choice D is incorrect as gender roles in traditional Arab American culture can vary and may not always follow a strict hierarchical structure.