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The nurse is performing a neurological assessment on a client with a diagnosis of dementia and assessing the function of the frontal lobe of the brain. Which should the nurse assess to yield the best information about this area of functioning?
- A. Eye movements
- B. Feelings or emotions
- C. Level of consciousness
- D. Insight, judgment, and planning
Correct Answer: D
Rationale: Insight, judgment, and planning are part of the function of the frontal lobe. Eye movements are under the control of cranial nerves III, IV, and VI. Feelings and emotions are part of the role of the limbic system. The level of consciousness is controlled by the reticular activating system.
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What feeling is likely to result from withdrawn behavior?
- A. Anger
- B. Paranoia
- C. Loneliness
- D. Boredom
Correct Answer: C
Rationale: Withdrawn behavior involves avoiding social interactions and isolating oneself. This isolation can lead to feelings of loneliness as the individual lacks connection and companionship. While anger or paranoia may contribute to withdrawal, loneliness is a common emotional consequence of prolonged social isolation. Boredom may also arise from withdrawal if meaningful activities and social engagements are reduced.
A client who is to undergo dilation and curettage and conization of the cervix for cancer appears tense and anxious. Which approach would the nurse use to support the client emotionally?
- A. Explaining that these procedures are considered minor surgery
- B. Asking whether something is troubling the client and whether she'd like to talk about it
- C. Stating that the procedures are routine and asking what the client is really worried about
- D. Explaining that everyone is fearful before the surgery even though there is little reason to worry
Correct Answer: B
Rationale: The correct approach for the nurse to support the client emotionally is to ask whether something is troubling the client and if she would like to talk about it. This approach acknowledges the client's anxiety and encourages communication without dismissing her feelings. Option A, explaining that the procedures are minor surgery, may invalidate the client's emotions. Option C assumes the client is worried about something specific, which may not be the case, leading to miscommunication. Option D provides false reassurance and may hinder open communication by dismissing the client's feelings as unwarranted.
The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?
- A. The client is going through a grieving period.
- B. The client talks as if another person is affected.
- C. The client is willing to learn techniques to adapt.
- D. The client recognizes the reality and becomes anxious.
Correct Answer: D
Rationale: In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.
A client is having a panic attack. Which nursing intervention has priority for this client?
- A. have the client recount a positive childhood memory
- B. provide the client with a glass of water
- C. tell the client to take deep breaths
- D. ask the client to identify the source of his anxiety
Correct Answer: C
Rationale: Deep breathing helps reduce hyperventilation and physiological symptoms during a panic attack, making it the priority intervention.
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.