Nokea
The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?
- A. The client is going through a grieving period.
- B. The client talks as if another person is affected.
- C. The client is willing to learn techniques to adapt.
- D. The client recognizes the reality and becomes anxious.
Correct Answer: D
Rationale: In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.
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Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.
- A. Emotional: room coldness
- B. Environmental: boredom
- C. Physical: pain
- D. Communication: silence
Correct Answer: C
Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.
According to psychodynamic theory, what purpose do delusions serve?
- A. Delusions are a defense against anxiety caused by real or imagined threats.
- B. Magical thinking is a delusion that ensures desirable outcomes.
- C. Delusions are a method of dealing with and interpreting external stimuli.
- D. Subconsciously, delusions are a way to safely express anger and hostility.
Correct Answer: A
Rationale: According to psychodynamic theory, delusions serve as a defense mechanism against anxiety triggered by real or perceived threats. Delusions are the individual's unconscious way of protecting themselves from overwhelming feelings of anxiety. Magical thinking, on the other hand, involves believing that one's thoughts can influence external events. This is not the same as delusions. Delusions are not a way of interpreting external stimuli but rather a defense mechanism. Expressing anger and hostility is typically associated with defense mechanisms like displacement or projection, not delusions.
What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?
- A. Scheduling pain medication at regular intervals
- B. Administering the medication only when the pain is severe
- C. Avoiding the administration of medication unless it is requested
- D. Recognizing that less pain medication will be needed by this client compared with other women in labor
Correct Answer: A
Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.
A neonatal intensive care nurse is caring for a newborn with a suspected diagnosis of erythroblastosis fetalis. Which therapeutic statement should the nurse make to the parents at this time?
- A. Your infant is very sick. The next 24 hours are the most crucial.'
- B. This is a common neonatal problem, so the prognosis is very good.'
- C. You have reason to worry but we have everything needed to care for your baby right here in this hospital.'
- D. You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care.'
Correct Answer: D
Rationale: The nurse should use therapeutic communication to address the parents' concerns and provide an opportunity for them to ask questions about their infant's care. Option 4 encourages open dialogue and supports the parents emotionally, which is critical during this stressful time. Option 1 may heighten anxiety without offering constructive support. Option 2 inaccurately minimizes the severity of erythroblastosis fetalis. Option 3 acknowledges worry but focuses on hospital resources rather than addressing the parents' emotional needs directly.
A client who was admitted for the treatment of thyroid storm (hyperthyroidism) is preparing for discharge. The client is anxious about the illness and is, at times, emotionally labile. Which intervention is most appropriate for the nurse to implement at this time?
- A. Assist the client with identifying coping skills, support systems, and potential stressors.
- B. Avoid teaching the client anything about the disease until he or she is emotionally stable.
- C. Reassure the client that everything will usually be fine after returning to one's home and family.
- D. Explain that being able to control of one's behavior must be achieved being discharge to home can occur.
Correct Answer: A
Rationale: It is normal for clients who experience thyroid storm (hyperthyroidism) to continue to be anxious and emotionally labile at the time of discharge. The best intervention is to help the client cope with these changes in behavior and to anticipate potential stressors so that symptoms will not be as severe. Options 2 and 3 block communication by either avoiding the issue or providing false reassurance. The confrontation described in option 4 will only heighten his anxiety.