Nokea
The nurse is planning care for a client who is experiencing anxiety after a myocardial infarction. Which priority nursing intervention should be included in the plan of care?
- A. Answer questions with factual information.
- B. Provide detailed explanations of all procedures.
- C. Encourage family involvement during the acute phase.
- D. Administer an antianxiety medication to promote relaxation.
Correct Answer: A
Rationale: Accurate information reduces fear, strengthens the nurse-client relationship, and assists the client with dealing realistically with the situation. Providing detailed information may increase the client's anxiety. Information should be provided simply and clearly. Encouraging family involvement may or may not be helpful. Medication should not be used unless necessary.
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The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client?
- A. Grief
- B. Socialization issues
- C. Issues related to sensory perception
- D. Trouble with coping with a disease process
Correct Answer: D
Rationale: A client with Graves' disease may become irritable, nervous, or depressed. The signs and symptoms in the question support option 4. The information in the question does not support the remaining options.
A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, 'Do I have to worry about this diabetes anymore?' Which is the most appropriate response by the nurse?
- A. Your blood glucose level is within normal limits now, so you will be all right.'
- B. You will have to worry about the diabetes only if you become pregnant again.'
- C. You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus.'
- D. When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life.'
Correct Answer: C
Rationale: The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk for developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus; however, with proper care, it may not develop.
The nurse is caring for a teenage client diagnosed with anorexia nervosa. The client's mother asks the nurse about eating disorders in general. Which information would the nurse provide? Select all that apply.
- A. Anorexia nervosa is more common than bulimia.
- B. Clients with bulimia may have erosion of the tooth enamel.
- C. Binging and purging can occur in both anorexia nervosa and bulimia.
- D. Extreme exercising and calorie restriction is common with anorexia nervosa.
- E. Clients with eating disorders may develop the disorders because of issues of power and control.
- F. Clients with anorexia have a distorted body image and think that they are fat even if they are very thin.
Correct Answer: B,C,D,E,F
Rationale: Bulimia is more common than anorexia, making A incorrect. Tooth enamel erosion, binging/purging, extreme exercising, power/control issues, and distorted body image are all accurate.
A client with the diagnosis of mania is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in the plan of care before seclusion?
- A. Ask the client if she understands why the seclusion is necessary.
- B. Remain silent because verbal interaction would be too stimulating.
- C. Tell the client that she will be allowed to come out when she can behave.
- D. Inform the client that she is being secluded to help regain her self-control.
Correct Answer: D
Rationale: Seclusion is a process in which a client is placed alone in a specially designed room for protection and close supervision. This client is removed to a nonstimulating environment as a result of her behavior. Options 1, 2, and 3 are nontherapeutic actions. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.
Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
- A. Dissociation.
- B. Regression.
- C. Projection.
- D. Denial.
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.