Nokea
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
You may also like to solve these questions
The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.
A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client's anxiety, should now be limited?
- A. Radio
- B. Television
- C. Family visitors
- D. Antianxiety medications
Correct Answer: D
Rationale: Antianxiety medications and opioid analgesics are used cautiously in the client who is being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The client may exhibit anxiety during the weaning process for a variety of reasons; therefore, distractions such as radio, television, and visitors are still very useful.
The parents of a newborn infant diagnosed with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which concern for the parents?
- A. Inability to cope with change
- B. Anger about lost opportunities
- C. Trouble adjusting to a child born with medical issues
- D. Depression associated with the birth of a child with defects
Correct Answer: D
Rationale: Depression is a normal part of the grieving process. It is a reaction to practical implications related to loss. Although the parents may have trouble adjusting and have anger, the best answer is to address their depression and sadness. The grief process includes intellectual and emotional responses and behaviors by which individuals and families work through the process of modifying their self-concepts on the basis of the perception of potential loss. Characteristics include expressions of sorrow and distress at the potential loss.
A client recovering from a brain attack (stroke) has become irritable and angry regarding self-limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable?
- A. Ignore the behavior, knowing that the client is grieving.
- B. Allow longer and more frequent visitation by the spouse.
- C. Use supportive statements to correct the client's behavior.
- D. Stress that the nurses are experienced and know how the client feels.
Correct Answer: C
Rationale: Clients who have experienced a stroke have many and varied needs. It is also important to support and praise the client for accomplishments. The client may need her or his behavior pointed out so that correction can take place, and the client's behavior should not be ignored. Spouses of a stroke client are often grieving; therefore, more visitations may not be helpful. Additionally, short visits are often encouraged. Stating that the nurse knows how the client feels is inappropriate.
The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is reporting insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse should recognize these complaints to be indications of which disorder?
- A. Phobia
- B. Dissociative disorder
- C. Obsessive-compulsive disorder
- D. Post-traumatic stress disorder (PTSD)
Correct Answer: D
Rationale: PTSD is precipitated by events that are overwhelming, unpredictable, and sometimes life threatening. Typical symptoms of PTSD include difficulty concentrating, sleep disturbances, intrusive recollections of the traumatic event, hypervigilance, and anxiety. These symptoms are not characteristic of the disorders noted in options 1, 2, and 3.