Nokea
The nurse is educating a group of student nurses about perceived loss. The nurse knows that the students understand when one of them verbalizes which example?
- A. a single mother loses her job
- B. a student fails his college chemistry class
- C. a husband is grieving the loss of his wife of 40 years
- D. a first-time mother is disappointed that she had a boy instead of a girl
Correct Answer: D
Rationale: Perceived loss involves subjective disappointment, such as a mother's expectation of a different gender, unlike tangible losses like a job or spouse.
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The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.
The nurse provides care for a client diagnosed with paranoid schizophrenia. The client’s spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate?
- A. Assign the client to straighten up the day room.
- B. Establish a trusting nurse-client relationship.
- C. Encourage the client to sleep and offer a sleep aid.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Encouraging sleep and offering a sleep aid addresses the client’s insomnia, which can exacerbate paranoia and schizophrenia symptoms. A trusting relationship is important but less urgent, and other options do not address the immediate need for rest.
A client diagnosed with acute kidney injury is having trouble remembering information and instructions as a result of altered laboratory values. Which actions should the nurse take when communicating with this client? Select all that apply.
- A. Give simple, clear directions.
- B. Include the family in discussions related to care.
- C. Explain treatments using understandable language.
- D. Explain the possibility of hemodialysis in simple terms.
- E. Give thorough and complete explanations of treatment options.
Correct Answer: A,B,C,D
Rationale: The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and altered laboratory values. Communications should be clear, simple, and understandable. The family is included whenever possible. Information about treatment should be explained using understandable language. Thorough and complete explanations may be confusing and will not be understandable for the client.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication should the nurse determine may be the best for the client?
- A. Use a picture or word board.
- B. Have the family interpret needs.
- C. Devise a system of hand signals.
- D. Use a pad of paper and a pencil.
Correct Answer: A
Rationale: The client with an endotracheal tube in place cannot speak, so the nurse devises an alternative communication system with the client. The use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. The family does not need to bear the burden of communicating the client's needs, and they may not understand the client either. The use of hand signals may not be a reliable method because it may not meet all needs, and it is subject to misinterpretation. A pad of paper and a pencil is an acceptable alternative, but it requires more client effort and time.