Nokea
Using clichés in therapeutic communication leads the client toward:
- A. viewing the nurse as human
- B. accepting himself as human
- C. self-disclosing
- D. feeling discounted
Correct Answer: D
Rationale: Clichés in communication can make clients feel dismissed or misunderstood, reducing trust and engagement in therapeutic interactions.
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A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that:
- A. Multiple drug use is very uncommon
- B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms
- C. Alcohol and barbiturates used together are not dangerous because one is a stimulant and the other is a depressant
- D. Assessment and intervention are easier with multiple drug use because of the synergistic effect
Correct Answer: B
Rationale: Multiple drug use is common to enhance effects or relieve withdrawal symptoms, complicating assessment and intervention due to varied drug interactions.
A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
- A. Actual Chronic Low Self-Esteem (related to obesity).
- B. Potential Chronic Low Self-Esteem (related to obesity).
- C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
- D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
Correct Answer: D
Rationale: If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem. The disturbance might be an anticipated one - that is, weight gain and pregnancy. Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self.
A 64 year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45 degree angle.
Correct Answer: C
Rationale: Both the family and the patient should have the need for restraints explained to them.
When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
- A. low-back pain
- B. urinary frequency
- C. GI distress
- D. malaise
Correct Answer: B
Rationale: Urinary frequency is least indicative of UTI during pregnancy because it is a common minor discomfort of pregnancy and is caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are no problems. Frequency returns in the third trimester when the uterus drops into the pelvic cavity. A UTI has the symptoms of frequency, back pain, supra pubic discomfort, and malaise and is diagnosed by laboratory findings.
When helping a client gain insight into anxiety, the nurse should:
- A. help relate anxiety to specific behaviors.
- B. ask the client to describe events that precede increased anxiety.
- C. instruct the client to practice relaxation techniques.
- D. confront the client's resistive behavior.
Correct Answer: B
Rationale: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.