Nokea
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
- A. Apply restraints to the client.
- B. Ask the family to stay with the client.
- C. Ask the laboratory to perform electrolyte studies.
- D. Reorient the client to time, place, and person frequently.
Correct Answer: D
Rationale: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.
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The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is reporting insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse should recognize these complaints to be indications of which disorder?
- A. Phobia
- B. Dissociative disorder
- C. Obsessive-compulsive disorder
- D. Post-traumatic stress disorder (PTSD)
Correct Answer: D
Rationale: PTSD is precipitated by events that are overwhelming, unpredictable, and sometimes life threatening. Typical symptoms of PTSD include difficulty concentrating, sleep disturbances, intrusive recollections of the traumatic event, hypervigilance, and anxiety. These symptoms are not characteristic of the disorders noted in options 1, 2, and 3.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
A client with the diagnosis of acute pyelonephritis who is very shy and modest is scheduled for a voiding cystourethrogram. Why should the nurse determine that this client would benefit from increased support and teaching about the procedure?
- A. Radioactive material is inserted into the bladder.
- B. Radiopaque contrast is injected into the bloodstream.
- C. The client must void while the voiding process is filmed.
- D. The client must lie on an x-ray table in a cold, barren room.
Correct Answer: C
Rationale: Having to void in the presence of others can be very embarrassing for clients, and it may actually interfere with the client's ability to void. The nurse teaches the client about the procedure to try to minimize stress from a lack of preparation and gives the client encouragement and emotional support. Screens may be used in the radiology department to try to provide an element of privacy during this procedure. The remaining options are incorrect and do not address the subject of support.
A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?
- A. The client is projecting by insisting that walking is the rehabilitation goal.
- B. To speed acceptance, the client needs reinforcement that he will not walk again.
- C. Denial can be protective while the client deals with the anxiety created by the new disability.
- D. The client needs to move through the grieving process rapidly to benefit from rehabilitation.
Correct Answer: C
Rationale: During the adjustment period that occurs the first few weeks after a spinal cord injury, clients may use denial as a defense mechanism. Denial may decrease anxiety temporarily, and it is a normal part of grieving. After the spinal shock resolves, the prolonged or excessive use of denial may impair rehabilitation. However, rehabilitation programs include psychological counseling to deal with denial and grief.
The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.