Nokea
The nurse is precepting a new nurse in the psychiatric unit. The nurse is discussing interventions for schizophrenia. Which statement by the student nurse indicates an understanding of management of schizophrenia? Select all that apply.
- A. I should be warm and friendly to put the client at ease.
- B. I can reassure the client that he is in a safe environment.
- C. Puzzles or word games are good activities to engage in.
- D. I can help the client use art or writing to express his feelings.
- E. I won't tell the client when I'm leaving him so he won't get upset.
Correct Answer: B,C,D
Rationale: Reassurance of safety, engaging activities like puzzles, and expressive therapies are appropriate. Overly warm approaches or withholding departure information can increase anxiety or mistrust.
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The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, 'I'm not sure about this. What if it doesn't work and I'm just as bad off as before?' Which concern for the client should the nurse identify at this time?
- A. Anxiety and depression
- B. Inability to handle the treatment regimen
- C. Lack of knowledge about the surgical procedure
- D. Fear about the potential risks and outcomes of surgery
Correct Answer: D
Rationale: This client has indicated the surgical procedure and its outcome as the object of fear. Anxiety is present when the client cannot identify the source of the uneasy feelings. Presently there are not indications that the client is depressed. A client's inability to handle a treatment regimen would be when the client is not making needed adaptations to deal with daily life. Lack of knowledge would be when there is a lack of appropriate information.
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. help the client bathe and change into fresh clothing before the examination begins
- B. preserve any evidence, including clothing, and take photographs of injuries as appropriate
- C. assure the client that surviving the assault is most important, and she did what was needed to stay alive
- D. take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
- E. tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (B), providing reassurance (C), and ensuring a private setting (D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will be required. The client becomes angry and states, 'I'll never be the same now.' Based on this information, which should the nurse identify as the client's primary concern?
- A. Anxiety about the hemodialysis
- B. Inability to think clearly because of the treatments needed
- C. Potential for noncompliance because of concerns about the disease
- D. Altered body image because of the physical changes that may occur
Correct Answer: D
Rationale: A client with a renal disorder such as CKD may become angry in response to the permanence of the condition. Because of the physical changes and the change in lifestyle that may be required to manage a severe renal condition, the client may experience an altered body image. Anxiety is not appropriate because the client is exhibiting anger at this time. The client is not cognitively impaired, eliminating option 2, and is not stating a refusal to undergo therapy, so eliminate option 3.
The nurse is caring for a client with a history of schizophrenia. The nurse asks the client if he is ready to eat his lunch. The client responds, 'Rain, train, down the drain, Jane's brain.' The nurse recognizes this type of speech pattern as which type?
- A. echolalia
- B. word salad
- C. neologisms
- D. clang association
Correct Answer: D
Rationale: Clang association is characterized by words chosen for their sound (e.g., rhyming or alliteration) rather than meaning, as seen in the client's response.