Nokea
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
- A. Scheduling weekly follow-up appointments
- B. Establishing contracts with available crisis resources
- C. Encouraging family and friends to be with the client at all times
- D. Providing phone numbers for the hospital and primary health care provider
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.
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A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
- A. Providing a supportive environment
- B. Examining intrapsychic conflicts and past issues
- C. Emphasizing social interaction with clients who are withdrawn
- D. Helping the client identify and examine dysfunctional thoughts and beliefs
Correct Answer: D
Rationale: Health promotion focuses on helping clients identify and examine dysfunctional thoughts, as well as identifying and examining the values and beliefs that maintain these thoughts. Providing a supportive environment is important, but it is not as primary as option 4 for this client. Examining intrapsychic conflicts and past issues is not directly related to the client's problem. Emphasizing social interaction is not appropriate at this time.
A client who was a victim of a gunshot incident states, 'I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.' Which strategy should the nurse include when initially formulating a therapeutic relationship?
- A. Teaching the client a variety of relaxation techniques
- B. Asking the psychiatrist to prescribe appropriate medication
- C. Encouraging the client to talk about the incident and feelings related to it
- D. Encouraging the client to think about just how lucky he or she is to still be alive
Correct Answer: C
Rationale: When developing a therapeutic relationship, it is important to acknowledge and validate the client's feelings. Although teaching the client relaxation techniques may be helpful at some point, it is not related to the subject of the question. Options 2 and 4 are nontherapeutic techniques, and they do not promote a therapeutic relationship.
A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
- A. Cerebral palsy is an infectious disease of the central nervous system.
- B. Cerebral palsy is an inflammation of the brain as a result of a viral illness.
- C. Cerebral palsy is a chronic disability characterized by difficulty with muscle control.
- D. Cerebral palsy is a congenital condition that results in moderate to severe retardation.
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
- A. Infection
- B. Fluid overload
- C. Impaired sleep patterns
- D. Inability to expectorate secretions
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.
The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Dorsal recumbent
Correct Answer: B
Rationale: IP therapy is the administration of chemotherapeutic agents into the peritoneal cavity. This therapy is used for intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery. The client should be placed in a semi-Fowler's position for this infusion because the client may experience nausea and vomiting caused by increasing pressure on the internal organs. Additionally, this treatment may also place pressure on the diaphragm. The positions indicated in the rest of the options would increase pressure in the peritoneal cavity.