Nokea
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
- A. Encourage the patient to talk about significant childhood religious experiences.
- B. Offer to take the patient to a revival the nurse's church is holding in the community.
- C. Read to the patient Bible passages that seem particularly relevant to the patient's case.
- D. Explore what the mobility, sight, and hearing changes mean to the patient.
Correct Answer: D
Rationale: The correct answer is D because exploring the impact of the mobility, sight, and hearing changes on the patient allows the nurse to address the patient's holistic needs, including spiritual distress. By understanding the patient's perspective on these changes, the nurse can provide support tailored to the patient's concerns, fostering a sense of connection and understanding.
Choice A is incorrect because focusing solely on childhood religious experiences may not address the current issues the patient is facing. Choice B is inappropriate as it imposes the nurse's religious beliefs on the patient. Choice C is also incorrect as it assumes a specific religious approach without considering the patient's individual beliefs and needs.
You may also like to solve these questions
A client diagnosed with bipolar disorder and experiencing mania is admitted to the inpatient psychiatric setting. During the acute phase of mania, which medication would the nurse expect to most likely administer?
- A. Lithium carbonate (Lithium)
- B. Haloperidol lactate (Haldol)
- C. Fluoxetine (Prozac)
- D. Paroxetine (Paxil)
Correct Answer: B
Rationale: The correct answer is B: Haloperidol lactate (Haldol). In the acute phase of mania, antipsychotic medications like haloperidol are commonly used to manage symptoms such as agitation, hyperactivity, and psychosis. Haloperidol helps to reduce dopamine activity in the brain, which can help stabilize mood and behavior during manic episodes. Lithium (A) is more commonly used for long-term mood stabilization in bipolar disorder. Fluoxetine (C) and Paroxetine (D) are selective serotonin reuptake inhibitors (SSRIs) used for depression and not recommended during mania due to the risk of worsening manic symptoms.
A nursing student is assigned to care for a patient diagnosed with schizophrenia. When talking about this patient in a clinical postconference, the student would use which terminology when referring to the patient?
- A. Committed patient
- B. Schizophrenic
- C. Schizophrenic patient
- D. Person with schizophrenia
Correct Answer: D
Rationale: The correct answer is D: Person with schizophrenia. This terminology aligns with person-first language, which emphasizes the individuality and humanity of the patient over their diagnosis. It is important to use person-first language to promote respect and reduce stigma. Using terms like "committed patient" (A) can be stigmatizing and inaccurate, as not all patients with schizophrenia are committed involuntarily. "Schizophrenic" (B) and "schizophrenic patient" (C) both label the individual by their diagnosis, which can be dehumanizing and reduce their identity to just their condition. In contrast, "person with schizophrenia" (D) acknowledges the personhood of the individual first and foremost.
A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks the nurse, 'How will this drug help me?' Which response by the nurse would be most appropriate?
- A. It will help to cure your alcoholism.'
- B. It can help to prevent you from drinking.'
- C. It makes the withdrawal symptoms less troublesome.'
- D. It helps to clear the alcohol out of your body.'
Correct Answer: B
Rationale: The correct answer is B: It can help to prevent you from drinking. Disulfiram works by causing unpleasant symptoms (such as nausea, vomiting, and headache) when alcohol is consumed, acting as a deterrent to drinking. This helps the client stay sober and avoid relapse.
Incorrect choices:
A: It will help to cure your alcoholism - Disulfiram does not cure alcoholism but helps manage it.
C: It makes the withdrawal symptoms less troublesome - Disulfiram does not address withdrawal symptoms.
D: It helps to clear the alcohol out of your body - Disulfiram does not clear alcohol from the body but rather prevents its metabolism, leading to adverse effects if alcohol is consumed.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.
A client on a psychiatric unit says,"It's a waste of time to be here. I can't talk to you or anyone." Which would be an appropriate therapeutic nursing response?
- A. "I find that hard to believe."
- B. "Are you feeling that no one understands?"
- C. "I think you should calm down and look on the positive side."
- D. "Our staff here is excellent, and you are in good hands."
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and encourages the client to express their feelings. By asking if the client feels that no one understands, the nurse acknowledges the client's emotions and opens the door for further discussion. Choice A is confrontational and may make the client defensive. Choice C dismisses the client's feelings and is not validating. Choice D is a vague reassurance that does not address the client's concerns.