Nokea
The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which statement is best for the nurse to make to the parents at this time?
- A. You should focus on your baby's personality, not appearance.
- B. Let me show you pictures of some babies before and after surgery.
- C. There are other problems with this condition that go beyond surgical correction.
- D. Has anyone else in either of your families had cleft lip or palate?
Correct Answer: B
Rationale: Showing pictures of successful surgical outcomes provides hope and tangible evidence of improvement, addressing the parents’ grief and concerns about appearance. Other options may dismiss emotions, overwhelm with additional concerns, or be irrelevant at this stage.
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The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?
- A. The client is going through a grieving period.
- B. The client talks as if another person is affected.
- C. The client is willing to learn techniques to adapt.
- D. The client recognizes the reality and becomes anxious.
Correct Answer: D
Rationale: In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.
The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?
- A. Amoxicillin is an antibiotic that will help you get well.
- B. This medicine tastes just like fresh strawberries.
- C. You can't drink anything for an hour after taking this medicine.
- D. If you don't want to drink this medicine, I can give you a shot instead.
Correct Answer: A
Rationale: Informing the client that amoxicillin is an antibiotic that will help them recover provides age-appropriate education about the medication’s purpose, promoting understanding and adherence. Other options may mislead or unnecessarily alarm the child.
A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?
- A. An attempt to punish the nursing staff
- B. A constructive method of accepting reality
- C. A defense against underlying depression and fear
- D. An effort to maintain life and to live it as fully as possible
Correct Answer: C
Rationale: The client's angry, critical communication and non-adherence to treatment suggest underlying emotional struggles. The behavior is likely a defense mechanism against feelings of depression and fear. It is essential to consider that the client's actions are not intentionally aimed at punishing others but rather a manifestation of internal distress. Option A is incorrect as the behavior is not about punishing the nursing staff. Option B is incorrect because the behavior is not a constructive way of accepting reality but rather a maladaptive coping mechanism. Option D is incorrect as the behavior is not primarily driven by an effort to maintain life but rather by emotional distress.
Based on Maslow's hierarchy of needs, which client is demonstrating characteristics of self-actualization?
- A. Client is competent and esteemed by others for accomplishing work goals
- B. Client maintains a stable, loving, same-sex partnership for several years
- C. Client learns to sublimate aggressive impulses using physical exercises
- D. Client has an accurate perception of reality and is accepting of self and others
Correct Answer: D
Rationale: According to Maslow's hierarchy of needs, self-actualization is the highest level where individuals strive to reach their full potential and achieve personal growth. A self-actualized person, as per Maslow, has an accurate perception of reality and is accepting of themselves and others. This individual is characterized by traits such as fairness, independence, spontaneity, and creativity. While choices A, B, and C represent important aspects of human needs fulfillment, they align more closely with lower levels in Maslow's hierarchy. Choice A refers to meeting self-esteem needs, choice B relates to love and belonging needs, and choice C addresses safety needs, all of which are below self-actualization in the hierarchy of needs.
A client diagnosed with cancer is placed on permanent total parenteral nutrition as a means of providing nutrition. Which is the rationale for the nurse to include psychosocial support when planning care for this client?
- A. Death is imminent.
- B. The client will need to adjust to the idea of living without eating by the usual route.
- C. Total parenteral nutrition requires disfiguring surgery for permanent port implantation.
- D. Nausea and vomiting occur regularly with this type of treatment and will prevent the client from participating in social activity.
Correct Answer: B
Rationale: Permanent total parenteral nutrition is indicated for clients who can no longer absorb nutrients via the enteral route. These clients will no longer take nutrition orally. The remaining options are inaccurate. There is no indication in the question that death is imminent. Permanent port implantation is not disfiguring. Total parenteral nutrition does not cause nausea and vomiting.