Nokea
The nurse is planning interventions for counseling a maternal client who has been newly diagnosed with sickle cell anemia. Which would be the most important psychosocial intervention at this time?
- A. Help the client identify her concerns.
- B. Avoid discussing the details of the disease.
- C. Allow the client to be alone if she is crying.
- D. Encourage family and friends to visit the client frequently.
Correct Answer: A
Rationale: One of the most important nursing roles is providing emotional support to the client and family during the counseling process. Option 2, like option 4, is nontherapeutic. Option 3 is only appropriate if the client requests to be alone; if this is not requested, the nurse is abandoning the client in a time of need. Option 4 overwhelms the client with information while she is trying to cope with the news of the disease.
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The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
- A. residual schizophrenia
- B. paranoid schizophrenia
- C. catatonic schizophrenia
- D. disorganized schizophrenia
- E. undifferentiated schizophrenia
Correct Answer: D
Rationale: Disorganized schizophrenia is characterized by social withdrawal, inappropriate affect, grimacing, and impaired daily functioning. Residual (A) involves milder symptoms, paranoid (B) involves delusions, catatonic (C) involves motor issues, and undifferentiated (E) lacks specific features.
A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information should the nurse initially provide to the client?
- A. It is very likely that the client will need dialysis within 5 to 10 years.
- B. One kidney is adequate to meet the needs of the body, as long as it has normal function.
- C. There is absolutely no chance of the client needing dialysis because of the nature of the surgery.
- D. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.
Correct Answer: B
Rationale: Fears about having only one functioning kidney are common among clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs as long as it has normal function. This information supports that the remaining options are inaccurate.
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on?
- A. The financial status of the client
- B. Postoperative communication techniques
- C. Information given to the client by the surgeon
- D. The client's support systems and coping behaviors
Correct Answer: C
Rationale: The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation, but also to determine the starting point for teaching and to implement the education at the client's level. Although the remaining options may be components of the plan, they are not the initial focus.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, 'What's the use? I'll never remember all of this, and I'll probably die anyway!' The nurse determines that the client's statement is most likely due to which psychosocial concern?
- A. Anger about the new medical regimen
- B. The teaching strategies used by the nurse
- C. Insufficient financial resources to pay for the medications
- D. Anxiety about the ability to manage the disease process at home
Correct Answer: D
Rationale: Anxiety and fear often develop after heart failure, and they can further tax the failing heart. The client's statement is made in the middle of receiving self-care instructions. There is no evidence in the question to support option 1, 2, or 3.