Nokea
The nurse plans care for a client diagnosed with antisocial personality disorder. The client participates in group therapy. Which action is most important for the nurse to take during the group therapy session?
- A. Provide time to explore the client's past.
- B. Demonstrate acceptance of the client and the client's behavior.
- C. Set limits on the client in a nonpunitive manner.
- D. Encourage sublimation of the client's leadership potential.
Correct Answer: C
Rationale: Setting nonpunitive limits ensures a safe group environment, as clients with antisocial personality disorder may manipulate or disrupt. Exploring the past, accepting harmful behavior, or encouraging leadership without boundaries may enable negative behaviors.
You may also like to solve these questions
When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?
- A. Listen to the parents' description of the child's behavior.
- B. Compare the child's function from one occasion to another.
- C. Engage the parents in a discussion about the child's feelings.
- D. Determine the child's mental status through direct questioning.
Correct Answer: B
Rationale: To accurately assess the mental status of a young school-aged child, it is crucial for the nurse to compare the child's function over time. This approach allows for a more objective evaluation of the child's mental status. While listening to the parents' description of the child's behavior can provide valuable insights, it may be biased and subjective. Engaging parents in discussions about the child's feelings is important for overall understanding but may not directly assess the child's mental status. Directly questioning the child about their mental status can be threatening and may lead to anxiety, making it a less optimal approach compared to observing and comparing the child's function over time.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The physical demands of the client's lifestyle
- B. The ability to comply with anticoagulant therapy for life
- C. The ability to participate in a cardiac rehabilitation program
- D. The likelihood of the client experiencing body image problems
Correct Answer: B
Rationale: Mechanical valves carry the associated risk of thromboemboli, which require long-term anticoagulation with warfarin sodium. No data in the question indicate that physical demands exist in the client's lifestyle. Not all clients who undergo cardiac surgery require cardiac rehabilitation. Body image problems are important but not critical.
A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?
- A. Suggest that the client arrange for help at home
- B. Ask the client to describe her concerns more fully
- C. Tell the client to speak to her primary health care provider about her concerns
- D. Recommend that the client schedule times when family members can assist her
Correct Answer: B
Rationale: When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.
The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
- A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
- B. Recopy the care plan without the resolved diagnosis
- C. Write a nursing progress note indicating that the outcome goals have been achieved
- D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
Correct Answer: D
Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
- A. I can understand what you mean. I'd be nervous too if I were in your shoes.
- B. This surgery is so successful that I wouldn't be concerned at all if I were you.
- C. Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.
- D. Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens.
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.