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.
You may also like to solve these questions
A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?
- A. What occurred prior to the rape, and when did you go to the emergency department?
- B. What would you like to talk about?
- C. I notice you seem uncomfortable discussing this.
- D. How can we help you feel safe during your stay here?
Correct Answer: B
Rationale: The correct answer is B because it allows the client to lead the conversation and express their concerns freely. By asking, "What would you like to talk about?" the nurse demonstrates empathy, respect, and openness to the client's needs, facilitating a client-centered approach. Choice A is specific and may not be what the client wants to discuss. Choice C reflects the nurse's observation rather than encouraging the client to share. Choice D focuses on the nurse's agenda rather than the client's preferences.
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
- A. History of alcohol dependence
- B. History of personality disorder
- C. History of schizophrenia
- D. History of hypertension
Correct Answer: A
Rationale: The correct answer is A: History of alcohol dependence. Alprazolam is a benzodiazepine and can be addictive, especially for individuals with a history of substance abuse like alcohol dependence. This client population is at higher risk for misuse, addiction, and overdose. It is important for the nurse to question this order to avoid potential harm. Choices B, C, and D are incorrect as they do not directly impact the safety or efficacy of alprazolam for acute anxiety.
In the role of milieu manager, which activity should the nurse prioritize?
- A. Setting the schedule for the daily unit activities
- B. Evaluating clients for medication effectiveness
- C. Conducting therapeutic group sessions
- D. Searching newly admitted clients for hazardous objects
Correct Answer: D
Rationale: The correct answer is D, searching newly admitted clients for hazardous objects. As a milieu manager, ensuring the safety of clients is a top priority. Searching for hazardous objects upon admission is crucial to prevent harm. Setting schedules (A) can be important but not as urgent as ensuring safety. Evaluating medication effectiveness (B) is important but not the primary role of a milieu manager. Conducting group sessions (C) is valuable for therapy but ensuring physical safety takes precedence.
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.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.