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What action would be most appropriate for the nurse to minimize agitation in a disturbed client?
- A. Ensure minimal staff contact.
- B. Increase environmental sensory stimulation.
- C. Limit unnecessary interactions with the client.
- D. Discuss reasons for the client's suspicions.
Correct Answer: C
Rationale: The most appropriate action to minimize agitation in a disturbed client is to limit unnecessary interactions. This approach helps reduce stimulation, thus decreasing agitation. Constant staff contact can lead to increased stimulation and agitation. Increasing environmental sensory stimulation can overwhelm the client's senses and escalate agitation. Discussing suspicions may not be beneficial as not all disturbed clients are suspicious and the client may not be in a state to engage in such discussions effectively.
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The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
- A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
- B. Recopy the care plan without the resolved diagnosis
- C. Write a nursing progress note indicating that the outcome goals have been achieved
- D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
Correct Answer: D
Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practices?
- A. Spiritual beliefs
- B. Family practices
- C. Emotional factors
- D. Cultural background
Correct Answer: B
Rationale: The correct answer is 'Family practices.' In this scenario, the client's health practices are influenced by the fact that her family members never had annual gynecologic examinations, leading her to believe that such preventive care measures are unnecessary. This highlights the impact of familial behavior on an individual's perception of healthcare. Spiritual beliefs are not the primary factor at play here; they may affect the choice of medical treatment but not the decision to seek preventive care. Emotional factors like stress or fear could influence health practices, but there is no indication of this in the client's case. Cultural background would come into play if the client followed specific health beliefs or customary practices related to illness and health restoration.
Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?
- A. Touch
- B. Silence
- C. Focusing
- D. Summarizing
Correct Answer: C
Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.
The nurse plans care for a client diagnosed with antisocial personality disorder. The client participates in group therapy. Which action is most important for the nurse to take during the group therapy session?
- A. Provide time to explore the client's past.
- B. Demonstrate acceptance of the client and the client's behavior.
- C. Set limits on the client in a nonpunitive manner.
- D. Encourage sublimation of the client's leadership potential.
Correct Answer: C
Rationale: Setting nonpunitive limits ensures a safe group environment, as clients with antisocial personality disorder may manipulate or disrupt. Exploring the past, accepting harmful behavior, or encouraging leadership without boundaries may enable negative behaviors.
The nurse is caring for a client with end-stage kidney disease and multiple organ failure. Which action by the nurse indicates an understanding of end-of-life care? Select all that apply.
- A. The nurse explains signs and symptoms that indicate death is near.
- B. The nurse explains to the client and family what to expect during the final phase of the illness.
- C. Cultural beliefs are acknowledged, but priority is placed on life-lengthening treatment options.
- D. The nurse avoids talking to the client about impending death to avoid upsetting him and the family.
- E. The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation.
Correct Answer: A,B,E
Rationale: Explaining signs of nearing death (A), what to expect (B), and discussing goals/wishes (E) support informed, compassionate end-of-life care. Prioritizing life-lengthening treatments (C) disregards palliative focus, and avoiding death discussions (D) hinders open communication.