Nokea
To decrease a client's use of denial and increase the client's expression of feelings, what should the nurse do?
- 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 most appropriate approach to decrease a client's use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.
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How can medication bound to protein affect drug availability?
- A. enhanced drug availability
- B. rapid distribution of the drug to receptor sites
- C. less availability to produce desired medicinal effects
- D. increased metabolism of the drug by the liver
Correct Answer: C
Rationale: Medication bound to protein reduces the availability of the drug to produce desired medicinal effects because only unbound drugs can effectively bind to active receptor sites. When a drug is bound to protein, it cannot bind with receptor sites, limiting its therapeutic impact. Choice A is incorrect because drug availability is reduced when it is bound to protein. Choice B is incorrect as rapid distribution to receptor sites is not possible if the drug is bound to protein and cannot bind with receptors. Choice D is incorrect as metabolism does not increase when the drug is bound to protein; the liver first needs to separate the drug from the protein before metabolism can occur.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. "How did you get those bruises?"?
- B. "Did someone grab you by your arms?"?
- C. "Do you fall often?"?
- D. "What did you bump against?"?
Correct Answer: B
Rationale: When addressing suspected abuse, it is crucial to ask direct questions to determine the cause of injuries. Choice B is the most appropriate as it directly inquires about the possibility of someone grabbing the client's arms, which could indicate abuse. This question can help uncover potential abuse and provide necessary intervention. Choices A, C, and D are less direct and may not elicit the critical information needed to address abuse effectively. Clients often hesitate to report abuse due to feelings of shame and fear of retaliation, making a direct approach essential in such situations.
A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?
- A. Neologism
- B. Word salad
- C. Clang association
- D. Associative looseness
Correct Answer: D
Rationale: The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.
A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?
- A. "I can drink alcohol now that I am decreasing my Xanax."?
- B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
- C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
- D. "I can expect to be sleepy for several days after stopping the medicine."?
Correct Answer: C
Rationale: The correct answer is that the client should take three pills per day next week, then two pills for one week, and then one pill for one week. This statement indicates a gradual tapering schedule, which is crucial when discontinuing alprazolam (Xanax) to prevent withdrawal symptoms. Choice A is incorrect because alcohol should be avoided while tapering off benzodiazepines due to the increased risk of respiratory depression. Choice B is incorrect because abruptly stopping alprazolam can lead to withdrawal symptoms. Choice D is incorrect because while drowsiness can be a side effect of alprazolam, it is not the primary concern when discontinuing the medication; preventing withdrawal symptoms is the priority.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalohematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: The correct answer is A, a cephalohematoma. A cephalohematoma is an area of bleeding outside the cranium but beneath the periosteum, typically not crossing the suture line. Answer B, molding, is the overlapping of the bones of the cranium and does not involve bleeding, making it an incorrect choice. Answer C, a subdural hematoma, involves intracranial bleeding and is typically diagnosed through imaging studies like a CAT scan or x-ray. Answer D, caput succedaneum, is characterized by edema that crosses the suture line, unlike the described swelling in this case.