Nokea
What action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?
- A. Removing the child's undergarments
- B. Placing the child's toys on the bedside table
- C. Allowing the child to climb onto the stretcher
- D. Having the parents accompany the child to the operating suite
Correct Answer: D
Rationale: The correct action is to have the parents accompany the child to the operating suite. Current practice encourages parents to stay with the child as long as possible to reduce stress related to a frightening experience. Removing the child's undergarments is usually not necessary for a myringotomy procedure. Placing the child's toys on the bedside table is important, especially a favorite one, for comfort until sedation is induced. Allowing the child to climb onto the stretcher may not be safe or appropriate as the child is too young to do so independently.
You may also like to solve these questions
Which source of stress would the nurse anticipate in a 5-year-old client?
- A. Jealousy
- B. Stubbornness
- C. Procrastination
- D. Companionship
Correct Answer: C
Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.
Which clinical findings indicate positive signs and symptoms of schizophrenia?
- A. Withdrawal, poverty of speech, inattentiveness
- B. Flat affect, decreased spontaneity, asocial behavior
- C. Hypomania, labile mood swings, episodes of euphoria
- D. Bizarre behavior, auditory hallucinations, loose associations
Correct Answer: D
Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.
Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?
- A. Getting angry is not appropriate; let's address this calmly.''
- B. Yelling is not acceptable and won't help us resolve this issue.''
- C. You must eat the first tray of food, and then I'll get another tray for you.''
- D. It must be frustrating to get the wrong tray. I'll order another tray for you.''
Correct Answer: D
Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.
Which behavior by the client exhibits denial after a recent diagnosis?
- A. Attempts to minimize the illness
- B. Lacks an emotional response to the illness
- C. Refuses to discuss the condition with the client's spouse
- D. Expresses displeasure with the prescribed activity program
Correct Answer: A
Rationale: The correct answer is 'Attempts to minimize the illness.' This behavior is a classic sign of denial, where the individual tries to downplay the seriousness of the illness to cope with it. By minimizing the illness, the client avoids facing the reality of the situation, which is characteristic of denial. Lacking an emotional response to the illness suggests suppression of emotions rather than denial. Refusing to discuss the condition with the spouse may stem from other issues like relationship strain or fear of causing distress, but it doesn't directly indicate denial. Expressing displeasure with the prescribed activity program typically reflects displaced anger, not denial of the illness.
Which benefit accompanies mild apprehension?
- A. Physiological functions are slowed.
- B. There is an increased alertness.
- C. Behavioral responses become automatic.
- D. Ego defense mechanisms are mobilized.
Correct Answer: B
Rationale: A mild level of anxiety can be beneficial because it increases alertness and focuses attention. Physiological functions are actually amplified initially, not slowed, due to mild apprehension; however, prolonged anxiety can lead to decreased function due to exhaustion. Automatic behavioral responses and ego defense mechanisms may hinder an individual's awareness rather than enhancing it, making them less beneficial compared to increased alertness.