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The parent of a child who was just diagnosed with hemophilia A is talking to the pediatric nurse. Which statement from the parent does the nurse respond to first?
- A. I feel so guilty-like it is all my fault.
- B. I do not know how we will afford this.
- C. It scares me to think my child will be bleeding all the time.
- D. We were looking forward to watching our child play sports.
Correct Answer: C
Rationale: The fear of constant bleeding indicates a misunderstanding of hemophilia and significant anxiety, which could impact caregiving. Addressing this concern first clarifies the condition and reduces fear, taking priority over guilt, financial worries, or lifestyle changes.
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Which comment made by the parents of a male infant who will have a surgical repair of a hernia indicates a need for further teaching by the nurse?
- A. I understand that surgery will repair the hernia.'
- B. I don't know if he will be able to father a child when he grows up.'
- C. The day nurse told me to give him sponge baths for a few days after surgery.'
- D. I'll need to buy extra diapers because we need to change them frequently now.'
Correct Answer: B
Rationale: The anatomical location of a hernia frequently causes more psychological concern to the parents than does the actual condition or treatment. The remaining options all indicate accurate understanding associated with the surgery. The correct option is an incorrect comment requiring follow-up.
A young female client hospitalized on the inpatient psychiatric unit receives treatment for anorexia nervosa. Which statement made by the client to the nurse best indicates improvement?
- A. The client states, 'I realize I am too thin and that it is not good for me, but I do not know how to eat more without getting fat.'
- B. The client requests a sanitary pad, saying, 'I did not think to bring anything with me. I have not had a period for months.'
- C. The client states, 'Either the food here is getting better or my appetite is coming back, but lately I find myself looking forward to meals.'
- D. The client asks for her discharge date to be delayed and says, 'I do not feel ready yet to deal with the tension in my family and their demands for perfection.'
Correct Answer: C
Rationale: Looking forward to meals indicates improved appetite and a positive shift in attitude toward eating, a key sign of progress in anorexia treatment. Other statements reflect awareness, physical changes, or anxiety, but do not directly indicate improved eating behavior.
The family of a client diagnosed with a myocardial infarction complicated by cardiogenic shock is visibly anxious and upset about the client's condition. Which should the nurse plan to implement to provide support to the family?
- A. Offer them coffee and other beverages on a regular basis.
- B. Insist that they go home to sleep at night to keep up their own strength.
- C. Ask the hospital chaplain to sit with them until the client's condition stabilizes.
- D. Provide flexible visiting times according to the client's condition and family needs.
Correct Answer: D
Rationale: The use of flexible visiting hours meets the needs of both the client and family for reducing the anxiety levels of both. Offering the family beverages does not provide support. Insisting that the family go home is nontherapeutic. Although the chaplain may provide support, it is unrealistic for the chaplain to stay until the client stabilizes.
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 older adult client who appears alert, oriented, and well-groomed shares with the nurse, 'Lately, I am seeing things that are not there. It is always people. I am awake and sitting down and I know they are not there, but I see them.' Which response by the nurse is appropriate?
- A. Has anyone in your family ever been diagnosed with schizophrenia?
- B. What medications have you been taking recently?
- C. Don't worry. You may actually have been asleep and dreaming.
- D. The Alzheimer organization offers some tests you may want to take.
Correct Answer: B
Rationale: Inquiring about medications explores potential causes of hallucinations, such as side effects, which is a common issue in older adults. Schizophrenia or Alzheimer’s assumptions are premature, and dismissing as dreaming ignores the client’s awareness.