Nokea
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.
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A perinatal home care nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption of 20 weeks' gestation. The client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the primary health care provider will be contacted for possible hospital admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, 'No, no, you can't go, my little man.' The nurse should recognize the client's behavior as an indication of which psychosocial reaction?
- A. Fear of hospitalization
- B. Fear of loss and the death of the fetus
- C. Grief due to potential loss of the fetus
- D. Cognitive confusion as a result of shock
Correct Answer: C
Rationale: Grief occurs when a client has knowledge of an impending loss, such as when signs of fetal distress accelerate. The first stages of grieving may be characterized by shock; emotional numbness; disbelief; and strong emotions such as tears, screaming, or anger. The remaining options are not focused on the mother's expressed concerns.
An English-speaking Hispanic client has a newly applied long leg cast to stabilize a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and unusually quiet. Which nursing statement would be most appropriate?
- A. Are you uncomfortable?
- B. Tell me what you are feeling.
- C. You'll feel better in the morning.
- D. I'll get your pain medication right away.
Correct Answer: B
Rationale: Option 2 is open-ended and makes no assumptions about the client's psychological or emotional state. Option 1 is incorrect because males in traditional standard Hispanic cultures practice 'machismo' in which stoicism is valued, so this client may deny any pain when asked. False reassurance is never therapeutic, which makes option 3 incorrect. Option 4 is incorrect because an assessment is necessary before administering medication for pain.
The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
- A. The termination stage begins with the initial group meeting.
- B. Members' feelings about their accomplishments are explored in the working stage.
- C. During the working stage, members may be unclear about the purpose of the group.
- D. Group roles and responsibilities are established in the working stage of group therapy.
Correct Answer: D
Rationale: Group roles and responsibilities are established in the working stage, when members actively engage in therapeutic goals.
A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, 'If my doctor tells me to do it, I will. Otherwise, I won't.' Which behavior should the nurse determine that the client is displaying?
- A. Anger
- B. Denial
- C. Depression
- D. Dependency
Correct Answer: D
Rationale: Clients may experience numerous emotional and behavioral responses after an MI. Dependency is one response that may be manifested by the client's refusal to perform any tasks or activities unless specifically approved by the primary health care provider. Although the client's statement may express anger to some degree, it most specifically addresses dependency. There are no data in the question to support denial or depression.
The nurse is caring for a client who says, 'I don't want to talk with you because you're only the nurse. I'll wait for my doctor.' Which statement should the nurse say in response to the client?
- A. I'm saddened by the way you dismissed me.
- B. I understand. So should I call your primary health care provider?
- C. Your primary health care provider directs me in your nursing care.
- D. So then, you would prefer to speak with your primary health care provider?
Correct Answer: B
Rationale: The nurse uses techniques of therapeutic communication to reflect the client's statement (option 2), redirect feelings back to the client for validation, and focus on the client's desire to talk with the doctor. Options 1 and 3 are nontherapeutic responses and are defensive responses. Option 4 reinforces the client's behavior and does not encourage client expression of feelings.