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The parents of a newborn infant diagnosed with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which concern for the parents?
- A. Inability to cope with change
- B. Anger about lost opportunities
- C. Trouble adjusting to a child born with medical issues
- D. Depression associated with the birth of a child with defects
Correct Answer: D
Rationale: Depression is a normal part of the grieving process. It is a reaction to practical implications related to loss. Although the parents may have trouble adjusting and have anger, the best answer is to address their depression and sadness. The grief process includes intellectual and emotional responses and behaviors by which individuals and families work through the process of modifying their self-concepts on the basis of the perception of potential loss. Characteristics include expressions of sorrow and distress at the potential loss.
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A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care?
- A. Attend a support group.
- B. Cease dwelling on the negative.
- C. Reach out for help to face this fear.
- D. Share her feelings with her partner.
Correct Answer: D
Rationale: Talking to the client about sharing her feelings with her husband directly addresses the subject of the question. Encouraging the client to start a support group will not address the client's immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client's concern.
The nurse is talking to a group of student nurses about content of thought in clients with schizophrenia. The nurse gives an example of a client stating that her new tooth filling allows her to communicate with the Secret Service and follow their directives. Which response correctly identifies this content of thought?
- A. somatic delusion
- B. delusion of grandeur
- C. delusion of persecution
- D. delusion of control or influence
Correct Answer: D
Rationale: A delusion of control or influence involves believing external forces or entities control one's thoughts or actions, as in the client's belief that a tooth filling enables communication with the Secret Service.
A client in the long-term care facility is confused and repeatedly asks the nurse for help finding the assigned room. Which response by the nurse is appropriate?
- A. Here is a map of the facility, including the room numbers.
- B. I think you can find your room if you just concentrate.
- C. Your room is on the first floor by the elevator doors.
- D. You didn't have any trouble finding your room yesterday.
Correct Answer: C
Rationale: Providing a clear, specific direction (room location by the elevator) helps orient the confused client without frustration. Maps are too complex, urging concentration is unhelpful, and referencing past ability may cause distress.
The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.)
- A. Keep the voice even throughout conversations.
- B. Explain the sounds in the environment.
- C. Decrease background noise before speaking.
- D. Stay in the client's field of vision.
- E. Identify self by name and staff position.
Correct Answer: A,B,C,D,E
Rationale: All options are appropriate: (A) Even voice tone ensures clarity; (B) Explaining sounds reduces confusion; (C) Reducing noise aids hearing; (D) Staying in the field of vision supports communication; (E) Identifying self orients the client. These interventions enhance safety and interaction.
A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client's anxiety, should now be limited?
- A. Radio
- B. Television
- C. Family visitors
- D. Antianxiety medications
Correct Answer: D
Rationale: Antianxiety medications and opioid analgesics are used cautiously in the client who is being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The client may exhibit anxiety during the weaning process for a variety of reasons; therefore, distractions such as radio, television, and visitors are still very useful.