Nokea
The nurse is caring for a client diagnosed with left-sided Bell's palsy. Which statement by the client shows a need for further teaching by the nurse?
- A. My left eye is tearing a lot.'
- B. I have trouble closing my left eyelid.'
- C. I don't know how I'll live with this stroke.'
- D. I can't feel anything on the left side of my face.'
Correct Answer: C
Rationale: Bell's palsy is an inflammatory condition that involves the facial nerve (cranial nerve VII). Although it results in facial paralysis, it is not the same as a stroke. Many clients fear that they have had a stroke when the symptoms of Bell's palsy appear, and they commonly believe that the paralysis is permanent. Symptoms resolve, although it may take several weeks. The remaining options are expected assessment findings of the client with Bell's palsy.
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The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
- A. administers medications as ordered
- B. uses gentle touch to reassure the client
- C. tells the client that others see or hear what he does
- D. distracts the client by placing him in the dayroom with others
- E. asks the client if he hears voices telling him to harm himself or others
Correct Answer: A,E
Rationale: Administering medications (A) helps manage hallucinations, and asking about harmful voices (E) assesses safety. Touch (B) may be misinterpreted, validating hallucinations (C) is harmful, and distraction in a dayroom (D) may overwhelm the client.
A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak to family or visitors. Which type of coping mechanism should the nurse assess the client is using?
- A. Denial
- B. Distancing
- C. Regression
- D. Suppression
Correct Answer: B
Rationale: Distancing is an unwillingness or inability to discuss events. The behaviors described are not associated with any of the other options.
The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse?
- A. Physical contact should be avoided whenever possible.
- B. The spouse would not feel or be harmed by the countershock.
- C. The shock would be felt, but it would not cause the spouse any harm.
- D. A warning device sounds before countershock, so there is time to move away.
Correct Answer: C
Rationale: Clients and families are often fearful about the activation of the ICD. Their fears are about the device itself and also about the occurrence of life-threatening dysrhythmias that trigger its function. Family members need reassurance that, even if the device activates while they are touching the client, the level of the charge is not high enough to harm the family member, although it will be felt. The ICD emits a warning beep when the client is near magnetic fields, which could possibly deactivate it, but it does not beep before countershock.
While providing care to a 12-year-old client, the nurse observes small round burn scars on the client's arms and legs, bruising on the buttocks, and tenderness of the right jaw. The client is anxious, has poor eye contact, and denies being injured at home when the nurse asks questions. Based on these observations, the nurse suspects victimization. Which is the next priority question the nurse should therapeutically ask the client in providing a safe environment for the client?
- A. Are you sure your parents didn't do this?
- B. You need to tell me now, or I'll call security, who did this to you?
- C. Is someone bullying you at school, or at home, or in your neighborhood?
- D. I can see this is difficult for you to talk about, you are safe here, but I need to ask you, who hurt you like this?
Correct Answer: D
Rationale: Based on the nurse's assessment data, the suspect of victimization needs to be analyzed to determine how the client received the old and new injuries. Option 4 offers the therapeutic approach for obtaining information using an open-ended question. It is important to determine if the injuries resulted from a family member or someone else outside the home. There are many forms of abuse besides physical abuse to consider such as sexual, emotional, and psychological abuse. Identifying the victimizer is important to stop the abuse and avoid further injuries. Safety is a priority concern for the client while in the care of the nurse and then after discharge from care. Option 1 implies that the nurse is challenging if the client is telling the truth. Option 2 could be perceived as demanding and a threat to the client to answer the question. Option 3 focuses on outside the family but there is not enough information given in the question to determine whether a family member is not suspected.
The nurse counsels the spouse of a client diagnosed with generalized anxiety disorder about how to cope with the client's anxiety. Which statement, made by the spouse, indicates that teaching is successful?
- A. Anxiety is a conscious means of resolving conflict.
- B. Anxiety represents an unconscious conflict of needs.
- C. I should confront my spouse when I notice signs of anxiety.
- D. Defense mechanisms increase anxiety.
Correct Answer: B
Rationale: Recognizing anxiety as an unconscious conflict of needs demonstrates understanding of its psychological basis, indicating successful teaching. Other statements are incorrect or promote unhelpful actions like confrontation.