Nokea
The nurse is developed a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication should the nurse base the teaching plan?
- A. Edema
- B. Hair loss
- C. Weight loss
- D. Decreased libido
Correct Answer: D
Rationale: The nurse should be aware of the fact that the client taking spironolactone, a potassium-sparing diuretic, may experience body image changes that result from a threatened sexual identity. These are related to decreased libido, gynecomastia in males, and hirsutism in females. Edema, weight loss, and hair loss are not specifically associated with the use of this medication.
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The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.)
- A. Keep the voice even throughout conversations.
- B. Explain the sounds in the environment.
- C. Decrease background noise before speaking.
- D. Stay in the client's field of vision.
- E. Identify self by name and staff position.
Correct Answer: A,B,C,D,E
Rationale: All options are appropriate: (A) Even voice tone ensures clarity; (B) Explaining sounds reduces confusion; (C) Reducing noise aids hearing; (D) Staying in the field of vision supports communication; (E) Identifying self orients the client. These interventions enhance safety and interaction.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
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 conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.
A client with a diagnosis of depression states to the nurse, 'I should have died. I've always been a failure.' Which therapeutic response should the nurse make to the client?
- A. You don't see anything positive?
- B. You still have a great deal to live for.
- C. Feeling like a failure is part of your illness.
- D. You've been feeling like a failure for some time now?
Correct Answer: D
Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate the exploration of the client's expressed feelings.