Nokea
The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take?
- A. Tell the client that the hospital is a safe place.
- B. Urge the client to reveal more information.
- C. Focus on developing a trusting relationship with the client.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Building trust is critical for clients with paranoia, who may be suspicious and guarded. A trusting relationship encourages engagement and cooperation, making it the priority over reassurance, urging disclosure, or socialization.
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During the admission assessment of a client with a history of alcohol abuse for diagnosis of ruptured esophageal varices, the client says, 'I deserve this. I brought it on myself.' Which response is most therapeutic for the nurse to make to the client?
- A. Would you like to talk to the chaplain?
- B. Is there some reason you feel you deserve this?
- C. Not all esophageal varices are caused by alcohol.
- D. That is something to think about when you leave the hospital.
Correct Answer: B
Rationale: Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic alcohol abuse. It is important to obtain an accurate history regarding the client's alcohol intake. If the client is ashamed or embarrassed, he or she may not respond accurately. Option 2 is open-ended and allows the client to discuss his or her feelings about drinking. Option 1 blocks the nurse-client communication process. Options 3 and 4 are somewhat judgmental.
A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, 'I know I need it, but I'm not sure this surgery is a great idea.' Which nursing response should best help the nurse assess the client's preoperative concerns?
- A. How does your family feel about the surgery?
- B. Has anyone taught you about the procedure yet?
- C. You sound extremely worried. Has anyone told you that the technology is really quite safe?
- D. You sound uncertain about the procedure. Can you tell me more about what has you concerned?
Correct Answer: D
Rationale: Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's concerns. Options 2 and 3 are closed-ended and are not exploratory.
A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, 'Do I have to worry about this diabetes anymore?' Which is the most appropriate response by the nurse?
- A. Your blood glucose level is within normal limits now, so you will be all right.'
- B. You will have to worry about the diabetes only if you become pregnant again.'
- C. You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus.'
- D. When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life.'
Correct Answer: C
Rationale: The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk for developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus; however, with proper care, it may not develop.
The nurse is planning interventions for counseling a maternal client who has been newly diagnosed with sickle cell anemia. Which would be the most important psychosocial intervention at this time?
- A. Help the client identify her concerns.
- B. Avoid discussing the details of the disease.
- C. Allow the client to be alone if she is crying.
- D. Encourage family and friends to visit the client frequently.
Correct Answer: A
Rationale: One of the most important nursing roles is providing emotional support to the client and family during the counseling process. Option 2, like option 4, is nontherapeutic. Option 3 is only appropriate if the client requests to be alone; if this is not requested, the nurse is abandoning the client in a time of need. Option 4 overwhelms the client with information while she is trying to cope with the news of the disease.
The nurse is preparing to care for a child with anemia from a culture that is different from the nurse's. Which is the best way to address the cultural needs of the child and family when the child is admitted to the health care facility?
- A. Address only those issues that directly affect the nurse's care of the child.
- B. Ask questions, and explain to the family why the questions are being asked.
- C. Explain that cultural practices need to be discontinued during hospitalization.
- D. Ignore cultural needs because they are not important to health care professionals.
Correct Answer: B
Rationale: When caring for individuals from a different culture, it is important to ask questions about their specific cultural needs and means of treatment. An understanding of the family's beliefs and health practices is essential to successful interventions for that particular family. Eliminate the options that ignore the cultural beliefs and values of the client.