Nokea
The nurse is caring for a dying client who states, 'Will you be the executor of my will?' How should the nurse best respond to this client?
- A. I must decline your offer because I am your nurse.
- B. I will carry out your will according to your wishes.
- C. It is an honor to be named the executor of your will.
- D. Tell me more so that I can understand your thinking.
Correct Answer: D
Rationale: The client's question reflects his thoughts about the will and how to obtain an executor, but the question does not reveal why the client is asking the nurse to be executor, and it also does not address other important information. In option 4, the nurse seeks clarification while acknowledging the client's statement. Most agencies do not allow the nurse to be the executor of a client's will (option 3). The other options fail to regard the potential consequences, think critically, or explore the client's motivation and needs.
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A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.
- A. panic attacks
- B. impaired short-term memory
- C. auditory hallucinations
- D. inability to leave home
Correct Answer: A,D
Rationale: Agoraphobia involves panic attacks and fear of leaving safe environments, leading to inability to leave home. Memory issues and hallucinations are not typical.
Based on Maslow's hierarchy of needs, which client is demonstrating characteristics of self-actualization?
- A. Client is competent and esteemed by others for accomplishing work goals
- B. Client maintains a stable, loving, same-sex partnership for several years
- C. Client learns to sublimate aggressive impulses using physical exercises
- D. Client has an accurate perception of reality and is accepting of self and others
Correct Answer: D
Rationale: According to Maslow's hierarchy of needs, self-actualization is the highest level where individuals strive to reach their full potential and achieve personal growth. A self-actualized person, as per Maslow, has an accurate perception of reality and is accepting of themselves and others. This individual is characterized by traits such as fairness, independence, spontaneity, and creativity. While choices A, B, and C represent important aspects of human needs fulfillment, they align more closely with lower levels in Maslow's hierarchy. Choice A refers to meeting self-esteem needs, choice B relates to love and belonging needs, and choice C addresses safety needs, all of which are below self-actualization in the hierarchy of needs.
The home health nurse visits a client with a history of type 1 diabetes mellitus. The client has recently experienced permanent loss of vision and is having difficulty adjusting. Which action by the nurse is most appropriate?
- A. Ask the health care provider for a psychiatric referral.
- B. Recommend that the client join a support group.
- C. Warn the client that failure to adapt can increase risk for injury.
- D. Reassure client that a change in visual abilities does not change personal identity.
Correct Answer: D
Rationale: Reassuring the client that vision loss does not alter their personal identity addresses emotional adjustment, fostering hope and self-worth. Support groups are helpful but less immediate, and psychiatric referrals or warnings may not address the client’s current emotional needs.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The physical demands of the client's lifestyle
- B. The ability to comply with anticoagulant therapy for life
- C. The ability to participate in a cardiac rehabilitation program
- D. The likelihood of the client experiencing body image problems
Correct Answer: B
Rationale: Mechanical valves carry the associated risk of thromboemboli, which require long-term anticoagulation with warfarin sodium. No data in the question indicate that physical demands exist in the client's lifestyle. Not all clients who undergo cardiac surgery require cardiac rehabilitation. Body image problems are important but not critical.
Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?
- A. Undoing
- B. Projection
- C. Introjection
- D. Displacement
Correct Answer: A
Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.