Nokea
The nurse is assessing a client to determine the client's adjustment to presbycusis. Which indicates successful adaptation by the client to this problem?
- A. Proper use of a hearing aid
- B. Denial of a hearing impairment
- C. Withdrawal from social activities
- D. Reluctance to answer the telephone
Correct Answer: A
Rationale: Presbycusis occurs as part of the aging process; it is a progressive sensorineural hearing loss. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Some clients may not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid.
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The nurse provides care for a client diagnosed with paranoid schizophrenia. The client’s spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?
- A. Assign the client to straighten up the day room.
- B. Establish a trusting nurse-client relationship.
- C. Encourage the client to sleep and offer a sleep aid.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Encouraging sleep and offering a sleep aid addresses the client’s insomnia, which can exacerbate paranoia and schizophrenia symptoms. A trusting relationship is important but less urgent, and other options do not address the immediate need for rest.
A client who is experiencing suicidal thoughts shares with the nurse that, 'I was awake most of the night. It just doesn't seem worth it anymore. Why not just end it all?' Which response should the nurse make to best further assess the client?
- A. Did you sleep at all last night?
- B. Tell me what you mean by that.
- C. I know you have had a stressful night.
- D. I'm sure that your family is worried about you.
Correct Answer: B
Rationale: Option 2 allows the client the opportunity to tell the nurse more about what his or her current thoughts are. Option 1 changes the subject and may block communication. Although option 3 offers empathy to the client, it does not further assess the client. Option 4 is false reassurance and may block communication.
A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication should the nurse determine may be the best for the client?
- A. Use a picture or word board.
- B. Have the family interpret needs.
- C. Devise a system of hand signals.
- D. Use a pad of paper and a pencil.
Correct Answer: A
Rationale: The client with an endotracheal tube in place cannot speak, so the nurse devises an alternative communication system with the client. The use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. The family does not need to bear the burden of communicating the client's needs, and they may not understand the client either. The use of hand signals may not be a reliable method because it may not meet all needs, and it is subject to misinterpretation. A pad of paper and a pencil is an acceptable alternative, but it requires more client effort and time.
A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?
- A. The client is projecting by insisting that walking is the rehabilitation goal.
- B. To speed acceptance, the client needs reinforcement that he will not walk again.
- C. Denial can be protective while the client deals with the anxiety created by the new disability.
- D. The client needs to move through the grieving process rapidly to benefit from rehabilitation.
Correct Answer: C
Rationale: During the adjustment period that occurs the first few weeks after a spinal cord injury, clients may use denial as a defense mechanism. Denial may decrease anxiety temporarily, and it is a normal part of grieving. After the spinal shock resolves, the prolonged or excessive use of denial may impair rehabilitation. However, rehabilitation programs include psychological counseling to deal with denial and grief.
Fluoxetine hydrochloride is prescribed for a client with a diagnosis of depression. The nurse provides instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication?
- A. I should take the medication with my evening meal.
- B. I should take the medication at noon with an antacid.
- C. I should take the medication in the morning when I first arise.
- D. I should take the medication right before bedtime with a snack.
Correct Answer: C
Rationale: Fluoxetine hydrochloride is an antidepressant and is administered in the early morning without consideration of meals. The remaining options present either incorrect times or incorrect conditions to take this medication.