Nokea
The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn?
- A. A client who woke up from a nap recently, just ate a snack, and is sitting up in bed.
- B. A client who was just informed of a cancer diagnosis by the health care provider.
- C. A client recovering from a stroke who has returned from physical therapy.
- D. A client who received pain medication 5 minutes ago for relief of discomfort.
Correct Answer: A
Rationale: A client who is rested, nourished, and alert (after a nap and snack, sitting up) is in an optimal state for learning. Recent diagnosis, fatigue from therapy, or recent pain medication may impair readiness to learn.
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The nurse provides care for a client diagnosed with bulimia. Which nursing action is most helpful in determining what precipitates the client'sEating disorder?
- A. Observe the family communication patterns at a monitored mealtime.
- B. Distract the client at mealtimes.
- C. Assign the client a food/feelings/thoughts action journal.
- D. Ask the client to write a history of eating behaviors.
Correct Answer: C
Rationale: A food/feelings/thoughts journal helps identify triggers and patterns associated with binge-purge behaviors, providing insight into precipitants. Observing family dynamics is useful but less direct, and distraction or history-writing are less focused on current triggers.
A client is telling the nurse about his perception of his thought patterns. Which of the following statements by the client would validate the diagnosis of bipolar disorder?
- A. Sometimes I'm ready to take on the world, but other times I'm too tired to get out of bed.
- B. I need to check and then recheck all the kitchen appliances several times to make sure they are off before I feel comfortable leaving my home.
- C. My neighbors hold sacrificial rites in their backyard.
- D. I keep on patrol all night so the enemy won't invade my home and hurt me or my family.
Correct Answer: A
Rationale: This statement describes mood swings between mania and depression, characteristic of bipolar disorder.
A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring?
- A. The client has a home health aide coming to the house for 9 weeks.
- B. The client was going to stay with a daughter in the daughter's home indefinitely.
- C. The client was going to have blood work drawn in the home by a local laboratory.
- D. The client has a good friend living next door who would take the client to the doctor.
Correct Answer: B
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Option 2 provides a direct support system. Clients may need support systems in place to enhance compliance with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care.
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.
A client awaiting surgery for the removal of a pancreatic mass shares with the nurse concerns about not waking up after receiving the anesthesia. Which therapeutic response is most appropriate for the nurse to make to the client?
- A. This is a very common concern.
- B. Tell me what makes you feel concerned about the anesthesia.
- C. I had surgery a year ago and was afraid of the same thing. I did just fine.
- D. You have the best anesthesiologist in this hospital. There is no need to be scared.
Correct Answer: B
Rationale: This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic response to the client is the one that encourages the client to express her or his concerns. Option 1 is a stereotypical response. Option 3 avoids the client's concern and focuses on the nurse's personal experience. Option 4 also avoids the client's concern.