Nokea
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching?
- A. I check my weight every day without fail.'
- B. I exercise 3 to 4 hours every day to keep my slim figure.'
- C. I've been told that I am 10% below my ideal body weight.'
- D. My best friend was in the hospital with this disorder a year ago.'
Correct Answer: B
Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being.
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The nurse is caring for a client with end-stage kidney disease and multiple organ failure. Which action by the nurse indicates an understanding of end-of-life care? Select all that apply.
- A. The nurse explains signs and symptoms that indicate death is near.
- B. The nurse explains to the client and family what to expect during the final phase of the illness.
- C. Cultural beliefs are acknowledged, but priority is placed on life-lengthening treatment options.
- D. The nurse avoids talking to the client about impending death to avoid upsetting him and the family.
- E. The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation.
Correct Answer: A,B,E
Rationale: Explaining signs of nearing death (A), what to expect (B), and discussing goals/wishes (E) support informed, compassionate end-of-life care. Prioritizing life-lengthening treatments (C) disregards palliative focus, and avoiding death discussions (D) hinders open communication.
After undergoing dilation and curettage following an early miscarriage, a client is crying. Which response would the nurse give?
- A. This must be a very difficult experience for you to deal with.''
- B. You'll have other children to take the place of the child you lost.''
- C. Of course you're sad now, but at least you know you can get pregnant.''
- D. I know how you feel, but when a woman miscarries, it's usually for the best.''
Correct Answer: A
Rationale: The correct response acknowledges the client's grief without judgment and provides validation. Choice B is inappropriate as it suggests replacing the lost child with other children, which is insensitive and dismissive of the client's current loss. Choice C minimizes the client's feelings by focusing on the ability to get pregnant rather than addressing the emotional impact of the miscarriage. Choice D is dismissive and patronizing, suggesting that the miscarriage was for the best, which can be hurtful and diminish the client's grief.
What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?
- A. Scheduling pain medication at regular intervals
- B. Administering the medication only when the pain is severe
- C. Avoiding the administration of medication unless it is requested
- D. Recognizing that less pain medication will be needed by this client compared with other women in labor
Correct Answer: A
Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
- A. I can understand what you mean. I'd be nervous too if I were in your shoes.
- B. This surgery is so successful that I wouldn't be concerned at all if I were you.
- C. Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.
- D. Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens.
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.
A young adult client diagnosed with a spinal cord injury tells the nurse, 'It's so depressing that I'll never get to have sex again.' Which is the realistic reply for the nurse to make to the client?
- A. It must feel horrible to know you can never have sex again.'
- B. It's still possible to have a sexual relationship, but it will be different.'
- C. You're young, so you'll adapt to this more easily than if you were older.'
- D. Because of body reflexes, sexual functioning will be no different than before.'
Correct Answer: B
Rationale: It is possible to have a sexual relationship after a spinal cord injury, but it is different from what the client will have experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may help the client adapt to changes in sexuality after a spinal cord injury.