Nokea
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
- A. Have decreased anxiety.
- B. Talk to the nurse for 10 minutes.
- C. Sit quietly for 30 minutes.
- D. Develop an adaptive coping mechanism.
Correct Answer: B
Rationale: When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.
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The difference between spirituality and religion is that spirituality is:
- A. a belief about a higher power.
- B. an individual's relationship with a higher power.
- C. organized worship.
- D. a belief in an invisible energy or ideal.
Correct Answer: B
Rationale: The correct answer is 'an individual's relationship with a higher power.' Spirituality is more about personal connection, beliefs, and experiences related to a higher power or force, whereas religion is often associated with organized practices, rituals, and doctrines within a specific faith community. Choice A is incorrect as spirituality goes beyond just believing in a higher power; it encompasses a personal connection. Choice C, 'organized worship,' is incorrect because spirituality can exist outside formal religious settings. Choice D is incorrect as it oversimplifies spirituality as merely a belief in an invisible energy or ideal, missing the relational aspect with a higher power.
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
- A. Assessment of the client's level of anxiety
- B. Evaluation of the client's exercise tolerance
- C. Identification of peripheral pulses
- D. Assessment of bowel sounds and activity
Correct Answer: C
Rationale: The most crucial assessment during the preoperative period for a client with a sacular abdominal aortic aneurysm scheduled for surgical repair is the identification of peripheral pulses. During surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Therefore, it is essential for the nurse to assess peripheral pulses and monitor the return of circulation to the lower extremities postoperatively. Assessing the client's level of anxiety (Choice A) is important but not as crucial as ensuring adequate circulation. Evaluating exercise tolerance (Choice B) is not recommended preoperatively for this situation. Assessing bowel sounds and activity (Choice D) is of lesser concern compared to the critical need to monitor peripheral circulation.
A client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:
- A. touching the client to help him return to reality
- B. leaving the client alone until reality returns
- C. asking the client to describe what is happening
- D. telling the client there are no voices
Correct Answer: A
Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently. Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- A. Take the blood pressure, pulse, and temperature
- B. Ask the client to rate his pain on a scale of 0-5
- C. Watch the client's facial expression
- D. Ask the client if he is in pain
Correct Answer: B
Rationale: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. This method provides a more standardized and quantifiable measure of pain compared to subjective observations like facial expressions (choice C) or direct questioning (choice D). Monitoring vital signs (choice A) can be part of pain assessment but is not as specific or reliable as asking the client to self-report pain intensity.
A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in what type of charge?
- A. Fraud
- B. Tort
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: The correct answer is 'Fraud.' Identifying oneself as a nurse without a license defrauds the public and can lead to prosecution. A tort is a wrongful act in breach of a legal duty imposed by law; malpractice is the failure to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. In this scenario, the key issue is the misrepresentation of licensure status, which constitutes fraud. Therefore, choices B, C, and D are incorrect.