Nokea
Place the following phases of crisis in the correct sequential order. Order each response with a number from first to last, with #1 as the first phase of crisis to #4 which is the fourth phase of crisis. 1. The signs and symptoms of the General Adaptation Syndrome 2. Detachment and disorientation 3. Trying alternative methods of coping 4. The use of psychological ego defense mechanisms
- A. 3,2,1,4
- B. 1,2,3,4
- C. 4,3,2,1
- D. 4,3,1,2
Correct Answer: B
Rationale: The correct sequence of crisis phases typically follows: 1) General Adaptation Syndrome (initial stress response), 2) Detachment and disorientation (emotional response), 3) Trying alternative coping methods (problem-solving attempts), and 4) Use of psychological ego defense mechanisms (if coping fails). This reflects the progression of a crisis response.
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The nurse is teaching a client with a new diagnosis of hypertension about medication adherence. Which of the following statements by the client indicates a need for further teaching?
- A. I'll take my medication every morning.'
- B. I'll check my blood pressure regularly.'
- C. I'll stop my medication if I feel fine.'
- D. I'll avoid high-sodium foods.'
Correct Answer: C
Rationale: Stopping medication when feeling fine indicates a misunderstanding, as hypertension requires ongoing treatment.
A client with gastroesophageal reflux disease (GERD) reports chest discomfort that feels like heartburn, especially following each meal. After teaching the client to take antacids as prescribed, the nurse suggests that the client lie in which position during sleep?
- A. Prone with the head of the bed flat
- B. Supine with the head of the bed flat
- C. On the left side with the head of the bed flat
- D. With the head of the bed elevated 8 to 12 inches
Correct Answer: D
Rationale: The discomfort of reflux is aggravated by positions that allow the reflux of gastrointestinal contents. The client is instructed to remain upright for 1 to 2 hours after a meal and sleep with the head of the bed elevated to approximately 30 degrees (usually on 8- to 12-inch blocks). Lying flat will increase the episodes of reflux, resulting in chest discomfort.
A nurse is having difficulty establishing a relationship with an aggressive client. What strategy will most likely improve the relationship?
- A. The nurse and the client agree to work to improve their involvement in the therapeutic relationship.
- B. The nurse establishes goals for having only positive interactions with the client.
- C. The nurse agrees to be submissive so the client can dominate the relationship.
- D. The nurse seeks assistance from colleagues to become more aware of the quality of the interactions and more sensitive to the dynamics of communication.
Correct Answer: D
Rationale: Seeking colleague assistance enhances self-awareness and communication skills, improving the therapeutic relationship with an aggressive client.
The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
- A. Administer surfactant
- B. Provide high-flow oxygen
- C. Initiate antibiotic therapy
- D. Perform chest physiotherapy
Correct Answer: A
Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
- A. Hyperactive bowel sounds.
- B. Rigid abdominal wall.
- C. Explosive diarrhea.
- D. Excessive flatulence.
Correct Answer: B
Rationale: A rigid abdominal wall is a hallmark sign of peritonitis, indicating peritoneal inflammation, often due to perforation in diverticulitis.