Nokea
The nurse is caring for a client who is taking tricyclic antidepressants. Which statement by the client indicates that the medication is working properly?
- A. I haven't felt like going to work this week.
- B. I've joined a bridge club in my neighborhood.
- C. I sleep 12 hours a night and take a nap during the day.
- D. I have felt my heart racing since I started the medicine.
Correct Answer: B
Rationale: Joining a social activity like a bridge club indicates improved mood and engagement, a sign that the antidepressant is effective.
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On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. Which response would the nurse provide?
- A. It seems that you've changed your mind about rooming in.
- B. I think you're having difficulty caring for the baby.
- C. All right. I'll inform the other nurses of your decision.
- D. You must be tired. I'll bring the baby back at feeding time.
Correct Answer: A
Rationale: Stating that it seems that the client has changed her mind opens communication and allows the client to verbalize her thoughts and feelings. This response acknowledges the client's request without being judgmental. Stating that the client is having difficulty caring for the baby is presumptuous and could make the client defensive. Informing other nurses of the client's decision without exploring the reasons behind it may not address the client's concerns. Although the client may be tired, assuming this without further discussion may overlook the client's true feelings and needs, hindering effective communication and support.
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching?
- A. I check my weight every day without fail.'
- B. I exercise 3 to 4 hours every day to keep my slim figure.'
- C. I've been told that I am 10% below my ideal body weight.'
- D. My best friend was in the hospital with this disorder a year ago.'
Correct Answer: B
Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being.
What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?
- A. Feelings of guilt
- B. Need to control others
- C. Desire for punishment
- D. Excessive physical activity
Correct Answer: D
Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.
Which initial response would the nurse make to a 67-year-old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have an erection for several years?
- A. At your age, sex isn't that important.''
- B. That is a natural occurrence at your age.''
- C. You sound upset about not being able to have an erection.''
- D. Maybe it's time for you to speak to your primary health care provider about this.''
Correct Answer: C
Rationale: The correct response is, 'You sound upset about not being able to have an erection.' When a client discloses personal information, the nurse should respond in a non-judgmental manner to encourage further communication and gather more details. This response demonstrates empathy and understanding, opening the door for the patient to express his feelings and concerns. Choice A, 'At your age, sex isn't that important,' is dismissive and fails to address the client's emotions or concerns, potentially hindering open communication. Choice B, 'That is a natural occurrence at your age,' provides inaccurate information as the inability to have an erection is not considered a normal part of aging. Choice D, 'Maybe it's time for you to speak to your primary health care provider about this,' while important eventually, should not be the initial response as the nurse should first explore the client's feelings and concerns before discussing potential referrals or interventions.
Which instruction should the nurse provide to a preschool-age client to prevent altered growth and development?
- A. Trust
- B. Empathy
- C. Impulse control
- D. Problem-solving
Correct Answer: C
Rationale: Teaching a preschool-age child and their parents about the importance of impulse control is essential to prevent the risk of altered growth and development. Preschool-age children are at a stage where they are developing self-regulation skills, so teaching them to manage their impulses can help in their overall growth and development. Trust is a critical concept taught during infancy to foster secure attachments. Empathy is crucial for parents of toddlers to understand their child's emotions. Problem-solving skills are typically emphasized for school-age children to enhance cognitive development.