Nokea
The nurse is caring for a client diagnosed with Hodgkin's disease who will be receiving radiation and chemotherapy. Which statement by the client indicates a positive coping mechanism to be used during these treatments?
- A. I won't leave the house bald.'
- B. Losing my hair won't bother me.'
- C. I will be one of the few who doesn't lose my hair.'
- D. I have selected a wig, even though I will miss my own hair.'
Correct Answer: D
Rationale: A combination of radiation and chemotherapy often causes alopecia. To make use of positive coping mechanisms, the client must identify personal feelings and positive interventions to deal with side effects. None of the remaining options are positive coping mechanisms.
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The nurse is preparing a plan of care for a client demonstrating mania. Which interventions should be included in the plan of care?
- A. Place the client in seclusion.
- B. Ignore any client complaints.
- C. Use a firm and calm approach.
- D. Use short and concise explanations and statements.
- E. Remain neutral and avoid power struggles and value judgments.
- F. Firmly redirect energy into more appropriate and constructive channels.
Correct Answer: C,D,E,F
Rationale: A client with mania will be extremely restless, disorganized, and chaotic. Grandiose plans are extremely out of touch with reality, and judgment is poor. Interventions for the client in acute mania include using a firm and calm approach to provide structure and control, using short and concise explanations or statements because of the client's short attention span, remaining neutral and avoiding power struggles and value judgments, being consistent in approach and expectations and having frequent staff meetings to plan consistent approaches and to set agreed-on limits to avoid manipulation by the client, hearing and acting on legitimate client complaints, and redirecting energy into more appropriate and constructive channels.
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.
The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
A client who received an implanted port for intermittent chemotherapy says, 'I'm not sure if I can handle having a tube coming out of me. What will my friends think?' Which action should the nurse implement first?
- A. Show the client various central line catheters.
- B. Assure the client that his friends will understand.
- C. Explain that implanted ports are subcutaneous and not visible.
- D. Notify the primary health care provider of the client's concerns.
Correct Answer: C
Rationale: An implanted port is subcutaneous; it is not visible, and it has no external tubing. Tubing is used when an intravenous line is connected, and the port is accessed for therapy. The remaining options do not correct the client's confusion about the implanted port. Notifying the provider is not indicated. Inquiring about the client's friends is a reasonable response, but it can also provide false hope that the friends will be accepting. In addition, the nurse is likely to cause more anxiety and concern by providing information about the catheter's subcutaneous location. Showing various central line catheters is unlikely to be beneficial because the client will not be using them; in addition, this can heighten client anxiety and concerns.
A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement?
- A. A brain tumor presents with few sights/symptoms.
- B. It is true that brain tumors are easily recognizable.
- C. Brain tumors are never detected until very late in their course.
- D. The signs/symptoms of a brain tumor may be easily attributed to another cause.
Correct Answer: D
Rationale: Signs and symptoms of a brain tumor vary depending on location, and they may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and changes in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them during the normal grieving process. Options 1, 2, and 3 are inaccurate statements.