Nokea
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.
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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.
The parent of a child who was just diagnosed with hemophilia A is talking to the pediatric nurse. Which statement from the parent does the nurse respond to first?
- A. I feel so guilty-like it is all my fault.
- B. I do not know how we will afford this.
- C. It scares me to think my child will be bleeding all the time.
- D. We were looking forward to watching our child play sports.
Correct Answer: C
Rationale: The fear of constant bleeding indicates a misunderstanding of hemophilia and significant anxiety, which could impact caregiving. Addressing this concern first clarifies the condition and reduces fear, taking priority over guilt, financial worries, or lifestyle changes.
The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed?
- A. Psychodrama
- B. Reality therapy
- C. Psychoanalytic therapy
- D. Short-term dynamic psychotherapy
Correct Answer: A
Rationale: Psychodrama involves the enactment of emotionally charged situations. Reality therapy is used for individuals with cognitive impairment. Both short-term dynamic psychotherapy and psychoanalytic therapy depend on techniques that are drawn from psychoanalysis.
The nurse discovers a hospice client has expired. The family members are assembled in the facility's waiting room. Which of the following statements by the nurse would be the most appropriate?
- A. My condolences on the passing of your family member. You may visit him if you wish.
- B. I will give you some time to spend with your loved one. Let me know if you need anything.
- C. You should view your loved one as a way of saying farewell.
- D. It would be best if you not view your loved one just yet.
Correct Answer: B
Rationale: This statement offers support, gives the family autonomy, and invites further communication, which is sensitive and appropriate.
A client who is quadriplegic frequently makes lewd sexual suggestions and uses profanity. The nurse concludes that the client is inappropriately using displacement. Which concern should the nurse identify as being appropriate for this client?
- A. Disuse syndrome
- B. Lack of coping skills
- C. Negative body image
- D. Lack of awareness of surroundings
Correct Answer: B
Rationale: Lack of coping skills is evident when the client demonstrates an impaired ability to adapt to meeting life's demands and roles. This client is displacing feelings onto the environment instead of using them in a constructive fashion. Option 3 may be appropriate, but it has nothing to do with the displacement that the client is currently using. Options 1 and 4 have no relation to this situation.