Nokea
The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse?
- A. A male diagnosed with moderate hypertension.
- B. A male with newly diagnosed cataracts.
- C. A female with advanced Parkinson disease.
- D. A female diagnosed with early stage Lyme disease.
Correct Answer: C
Rationale: Clients with advanced Parkinson disease are at higher risk for abuse due to increased dependency, physical limitations, and potential cognitive impairments, making them vulnerable to neglect or mistreatment. Other conditions listed are less likely to increase vulnerability to the same extent.
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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.
The nurse is planning care for a client who is experiencing anxiety after a myocardial infarction. Which priority nursing intervention should be included in the plan of care?
- A. Answer questions with factual information.
- B. Provide detailed explanations of all procedures.
- C. Encourage family involvement during the acute phase.
- D. Administer an antianxiety medication to promote relaxation.
Correct Answer: A
Rationale: Accurate information reduces fear, strengthens the nurse-client relationship, and assists the client with dealing realistically with the situation. Providing detailed information may increase the client's anxiety. Information should be provided simply and clearly. Encouraging family involvement may or may not be helpful. Medication should not be used unless necessary.
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
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 having premature ventricular contractions states to the nurse, 'I'm so afraid that something bad will happen.' Which action by the nurse provides the most immediate help to the client?
- A. Telephoning the client's family
- B. Using a television to distract the client
- C. Having a staff member stay with the client
- D. Giving reassurance that nothing will happen to the client
Correct Answer: C
Rationale: When a client experiences fear, the nurse can provide a calm, safe environment by offering appropriate reassurance, using therapeutic touch, and having someone remain with the client as much as possible. Options 1 and 2 do not address the client's fear, and option 4 provides false reassurance.