Nokea
The client is a 35-year-old multiparous individual scheduled for a tubal ligation. The nurse assesses the client's emotional response to the planned procedure. Which factor in the client's history will contribute to the healthy resolution of any emotional problem associated with sterilization?
- A. Belief that the surgery will relieve her monthly dysmenorrhea
- B. Knowledge that her partner does not want to have any more children
- C. Feeling that her family is complete and she now has the children she planned for
- D. Recovery from her previous complicated birth and a desire to avoid another birth
Correct Answer: C
Rationale: The correct answer is feeling that her family is complete and she now has the children she planned for. Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should not be expected to have an effect on dysmenorrhea. The decision to undergo sterilization should be the individual's own choice and should not be influenced by others, including partners. Decisions regarding sterilization should ideally be made when the individual is not under stress, such as after recovery from a previous complicated birth. Therefore, the key factor contributing to a healthy resolution of emotional issues related to sterilization is the feeling of family completeness and achieving the planned number of children.
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Which intervention would the nurse implement to develop a caring relationship with the client's family?
- A. Deciding health care options for the client
- B. Identifying the client's family members and their roles
- C. Declining to inform the client's family after performing a procedure
- D. Refraining from discussing the client's health with the family
Correct Answer: B
Rationale: To establish a caring relationship with the client's family, the nurse should start by identifying the family members and understanding their roles in the client's life. This step is crucial in determining how they can contribute to the client's healthcare and support. Deciding healthcare options for the client (Choice A) is not the nurse's role; it should be a collaborative decision with the client and family. Declining to inform the client's family after a procedure (Choice C) goes against transparency and collaboration in care. Refraining from discussing the client's health with the family (Choice D) can hinder effective communication and support, which are essential in developing a caring relationship with the family.
When a man with dementia is admitted to a long-term care facility, his wife, who appears tired and angry, says in a sarcastic tone, 'Let's see what you can do with him.' Which response is therapeutic?
- A. It sounds like it's been difficult for you.'
- B. I don't understand what you mean.'
- C. I have experience with all types of clients.'
- D. It's too bad you didn't admit him sooner.'
Correct Answer: A
Rationale: The correct response is to acknowledge the caregiver's feelings and challenges without blaming them. Option A, 'It sounds like it's been difficult for you,' shows empathy and opens the channel of communication. Options B and C, 'I don't understand what you mean' and 'I have experience with all types of clients,' are nurse-focused responses that block effective communication. Option D, 'It's too bad you didn't admit him sooner,' is a hostile response that shifts the blame to the caregiver, which is not therapeutic in this situation.
Which of the following individuals is at the highest risk of suicide?
- A. An 80-year-old man who lost his wife last year
- B. A 36-year-old woman whose former neighbor committed suicide
- C. A 40-year-old married businessman
- D. A 46-year-old former alcoholic who has been sober for 12 years
Correct Answer: A
Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.
Which of the following is a typical assessment finding of a 24-year-old female with anorexia nervosa?
- A. Weight loss of more than 2% body fat
- B. Frequent binge-eating episodes followed by induced vomiting
- C. A history of poor academic performance and mediocre achievements
- D. Lack of menstruation
Correct Answer: D
Rationale: The correct answer is D: Lack of menstruation. Amenorrhea, or lack of menstruation, is a common occurrence in individuals with anorexia nervosa. The induced starvation from anorexia can disrupt hormone levels, leading to menstrual irregularities. This hormonal imbalance can result in amenorrhea, which can have long-term consequences such as osteoporosis and infertility. Choices A, B, and C are incorrect. Weight loss of more than 2% body fat may be a consequence of anorexia but is not a specific assessment finding. Frequent binge-eating episodes followed by induced vomiting are more characteristic of bulimia nervosa, not anorexia nervosa. A history of poor academic performance and mediocre achievements is not a typical assessment finding related to anorexia nervosa symptoms.
Which intervention would the nurse use to provide emotional support for a resident in a nursing home who recently immigrated from another country?
- A. Offer choices consistent with the resident's heritage.
- B. Assist the resident in adjusting to the nursing home culture.
- C. Ensure that the resident is treated respectfully like the other residents.
- D. Correct any misconceptions the resident may have about appropriate health practices.
Correct Answer: A
Rationale: When providing emotional support to a resident in a nursing home who recently immigrated from another country, it is essential for the nurse to offer choices that align with the resident's heritage. This approach respects the resident's cultural beliefs and practices, promoting a sense of familiarity and comfort. Assisting the resident in adjusting to the nursing home culture is important but may not address the specific emotional support needed. While ensuring that the resident is treated respectfully is crucial, offering choices consistent with the resident's heritage goes a step further by acknowledging and valuing the resident's cultural background. Correcting any misconceptions about health practices is essential, but in this context, emotional support through cultural sensitivity takes precedence.