The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?
- A. Educate the client on managing stress.
- B. Teach the client to maintain a balanced diet.
- C. Instruct the client to have regular health checkups.
- D. Ask the client to use sunscreen when working outdoors.
Correct Answer: A
Rationale: The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.
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The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?
- A. Domestic abuse
- B. Hydatidiform mole
- C. Excessive exercise
- D. Thrombocytopenic purpura
Correct Answer: A
Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.
Which behavior is most typical for clients with borderline personality disorder?
- A. Arrogant
- B. Eccentric
- C. Impulsive
- D. Dependent
Correct Answer: C
Rationale: The correct answer is 'Impulsive.' Clients with borderline personality disorder often exhibit impulsive, potentially self-damaging behaviors. Arrogance is more characteristic of narcissistic personality disorder, eccentric behavior aligns with schizotypal personality disorder, and dependent behavior is typical of dependent personality disorder. Therefore, the key feature of borderline personality disorder is impulsivity.
Which source of stress would the nurse anticipate in a 5-year-old client?
- A. Jealousy
- B. Stubbornness
- C. Procrastination
- D. Companionship
Correct Answer: C
Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.
An adolescent reports irregularity in menses. Her mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image. Which could be the reason for irregular menses?
- A. Bulimia
- B. Anorexia
- C. Orthorexia
- D. Binge eating disorder
Correct Answer: B
Rationale: The correct answer is 'Anorexia.' Anorexia is characterized by a lack of caloric intake motivated by a strong fear of gaining weight, leading to poor nutrition and potential irregular menses. Bulimia involves binge eating followed by compensatory behaviors. Orthorexia is characterized by an obsession with eating only healthy or 'pure' foods. Binge eating disorder is characterized by consuming large amounts of high-calorie food in a short period.
When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
- A. Tell me about your typical day before you were diagnosed with chronic lung disease.''
- B. Smoking and not doing the exercises will make your lung disease continue to get worse.''
- C. I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
- D. Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct Answer: A
Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
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