Nokea
The mother of a 5-month-old is being educated about her baby's nutrition by the nurse. Which statement by the mother indicates the need for further teaching?
- A. ''I'm going to try feeding my baby some rice cereal.''
- B. ''When he wakes at night for a bottle, I feed him.''
- C. ''I dip his pacifier in honey so he'll take it.''
- D. ''I keep formula in the refrigerator for 24 hours.''
Correct Answer: C
Rationale: The correct answer is ''I dip his pacifier in honey so he'll take it.'' This statement indicates a need for further teaching because honey should be avoided in infants due to the risk of infant botulism. Honey may contain spores of Clostridium botulinum, which can lead to serious illness in infants as they lack the necessary digestive enzymes to eliminate the spores. Feeding rice cereal, responding to night-time feedings, and storing formula in the refrigerator are appropriate practices for infant care, indicating understanding of the instructions.
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To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?
- A. Instruct in the use of the incentive spirometer.
- B. Elevate the head of the bed during all meals.
- C. Use aseptic technique to change the dressing.
- D. Encourage frequent ambulation in the hallway.
Correct Answer: D
Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.
A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?
- A. Client will verbalize that depression symptoms have lifted
- B. Client will identify life stressors that may be contributing to depression
- C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
- D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy
Correct Answer: B
Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management.
Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.
What nonverbal action should the nurse implement to demonstrate active listening?
- A. Sit facing the client.
- B. Cross arms and legs.
- C. Avoid eye contact.
- D. Lean back in the chair.
Correct Answer: A
Rationale: Active listening is effectively demonstrated through attentive verbal and nonverbal communication strategies. To convey active listening and show the client that the nurse is engaged and attentive, it is essential for the nurse to sit facing the client. This posture communicates openness and willingness to listen. Option B, crossing arms and legs, creates a barrier and can signal defensiveness or disinterest, making it an incorrect choice. Option C, avoiding eye contact, hinders the establishment of a connection and can convey disengagement. Option D, leaning back in the chair, may give the impression of disinterest or lack of engagement. Therefore, maintaining eye contact and sitting facing the client are crucial nonverbal actions to exhibit active listening and promote effective therapeutic communication.
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?
- A. 'You may not have enough energy before long to hold a big party.'
- B. 'Do you mean to say that you want to plan your funeral and wake?'
- C. 'Planning a party and thinking about all your friends sounds like fun.'
- D. 'You should be thinking about spending your last days with your family.'
Correct Answer: C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.
Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?
- A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
- B. A client reads a story about a traumatic event and then visualizes the result
- C. A client focuses on a negative thought in their mind while tapping their fingers
- D. None of the above
Correct Answer: A
Rationale: Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.