Nokea
The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known pathological dysfunction. Based on this information, the nurse determines that the client is experiencing which type of dysfunctional communication?
- A. Mutism
- B. Verbigeration
- C. Pressured speech
- D. Poverty of speech
Correct Answer: A
Rationale: Mutism is the absence of verbal speech. The client does not communicate verbally despite an intact physical and structural ability to speak. Verbigeration is the purposeless repetition of words or phrases. Pressured speech refers to a rapidity of speech that reflects the client's racing thoughts. Poverty of speech involves diminished amounts of speech or monotonic replies.
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The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which statement should the nurse make to the client to most encourage therapeutic communication?
- A. How could your home care nurse let this happen?
- B. Now that this problem is taken care of, I'm sure you'll be fine.
- C. I have some time if you would like to talk about what happened to you.
- D. I'm sure you now understand the importance of preventing this from occurring.
Correct Answer: C
Rationale: Option 3 encourages the client to discuss his or her feelings. Options 1 and 4 show disapproval, and option 2 provides false reassurance; these are nontherapeutic techniques.
The nurse is preparing to implement suicide precautions for an acutely suicidal client. Which nursing interventions are included with regard to these precautions?
- A. Maintain arm's length distance with the client at all times.
- B. Ensure that meal trays contain no glass or metal silverware.
- C. Carefully watch the client swallow each dose of medication.
- D. Conduct one-on-one nursing observation and interaction 24 hours a day.
- E. Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol.
- F. Allow the client to totally cover self with the bedcovers during sleep at night as long as the nurse is present.
Correct Answer: A,B,C,D,E
Rationale: Suicide precautions involve constant observation of the client by the nursing staff. This intense attention from the nurse provides for safety and also allows for constant reassessment of risk. Suicide precautions include maintaining arm's length distance with the client at all times; ensuring that meal trays contain no glass or metal silverware; carefully watching the client swallow each dose of medication; conducting one-on-one nursing observation and interaction 24 hours a day and explaining to the client the procedures involved with suicide precautions; and documenting client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol. During observation when the client is sleeping, the client's hands should always be in view and not under the bedcovers.
When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?
- A. Reassure the client that many obese individuals have concerns about sex.
- B. Remind the client that sexual relationships can remain unaffected by obesity.
- C. Determine the frequency of sexual intercourse.
- D. Ask the client to talk about specific concerns.
Correct Answer: D
Rationale: Option D is the best response as it allows the client to express her specific concerns, providing the nurse with valuable assessment data. This open-ended question encourages the client to share her worries and feelings, which can guide the nurse in addressing her unique needs. Options A and B make assumptions about the client's concerns based on her weight, potentially invalidating her feelings and inhibiting effective communication. Option C is premature as understanding the client's concerns should precede discussions about the frequency of sexual intercourse, which may not address the core issues the client is facing.
The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?
- A. Instruct the client to add regular exercise to their daily routine.
- B. Determine if the client has been keeping a sleep diary.
- C. Encourage the client to continue the routine until sleep is achieved.
- D. Ask the client to describe the routine they are currently following.
Correct Answer: D
Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.