The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this the nurse should:
- A. tell the client to stop using the defense mechanism of denial.
- B. positively reinforce each expression of feelings.
- C. instruct the client to express feelings.
- D. challenge the client each time denial is used.
Correct Answer: B
Rationale: The nurse should positively reinforce each expression of feelings.
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A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:
- A. wearing clothing that is too small for the child.
- B. the child being shaken.
- C. falling while learning to walk.
- D. parents trying to awaken the child.
Correct Answer: B
Rationale: Children who are shaken are frequently grasped by both upper arms. Symptoms of brain injury associated with shaking include decreased level of consciousness.
A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
- A. fluid volume excess.
- B. hyperkalemia.
- C. hypercalcemia.
- D. fluid volume deficit.
Correct Answer: D
Rationale: For a client with an elevated urine osmolarity, the nurse should assess the client for fluid volume deficit.
A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.
- A. You feel inadequate because you have never learned to balance a checkbook.
- B. You should have insisted your husband teach you about the finances.
- C. You are strong and will learn how to manage your finances after awhile.
- D. Why don't you take a class in basic finance from the local college?
Correct Answer: C
Rationale: The nurse can raise the client's self-esteem by communicating confidence the client can participate in actively finding solutions to the problem. The nurse also conveys the client is a worthwhile person by listening and accepting the client's feelings and praising the client for seeking assistance.
A two-year old has been in the hospital for 3 weeks and seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?
- A. Guilt
- B. Trust
- C. Separation anxiety
- D. Shame
Correct Answer: C
Rationale: Separation anxiety can easily occur after six months during hospitalization.
Herbal therapy has several indications for use. Primarily, herbal therapy is:
- A. used to treat many common complaints and diseases.
- B. used to promote certain types of low-carb diets.
- C. used as an adjunct to medications.
- D. used to create a diet without salt and carbohydrates.
Correct Answer: A
Rationale: Herbal therapy is used to treat many common complaints and diseases.