Nokea
Support-system enhancement includes all of the following except:
- A. determining the barriers to using support systems.
- B. discussing ways to help with others who are concerned.
- C. exploring life problems of the support-team members.
- D. involving spouse, family, and friends in the care and planning.
Correct Answer: C
Rationale: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.
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A woman asks, 'How much alcohol can I safely drink while pregnant?' The nurse's best response is:
- A. The amount of alcohol that is safe during pregnancy is unknown.'
- B. Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman.'
- C. Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy.'
- D. You can have a drink to help you relax and get to sleep at night.'
Correct Answer: A
Rationale: The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during pregnancy.
A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. You have nothing to worry about. You are in a safe place. Try to relax.'
- B. Has anything happened recently or in the past that might have triggered these feelings?'
- C. We have given you a medication that helps to decrease feelings of anxiety.'
- D. Take some deep breaths and try to calm down.'
Correct Answer: B
Rationale: Choice 2 provides support, reassurance, and an opportunity to gain insight into the cause of the anxiety. Choice 1 dismisses the client's feelings and offers false reassurance. Choices 3 and 4 do not allow the client to discuss his feelings, which he must do in order to understand and resolve the cause of his anxiety.
A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about:
- A. the pathophysiology and acting out behaviors of schizophrenia.
- B. support groups that can help the parents release their feelings of frustration.
- C. the prolonged recovery time and depressive effects of medicines to prevent relapse.
- D. motivational techniques that are effective in clients with schizophrenia.
Correct Answer: C
Rationale: The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene.
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
- A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
- B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
- C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
- D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus.
Correct Answer: B
Rationale: Larger-than-normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways. Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD).
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to being hospitalized
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and pain in her joints
Correct Answer: C
Rationale: Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.