Nokea
What feeling is likely to result from withdrawn behavior?
- A. Anger
- B. Paranoia
- C. Loneliness
- D. Boredom
Correct Answer: C
Rationale: Withdrawn behavior involves avoiding social interactions and isolating oneself. This isolation can lead to feelings of loneliness as the individual lacks connection and companionship. While anger or paranoia may contribute to withdrawal, loneliness is a common emotional consequence of prolonged social isolation. Boredom may also arise from withdrawal if meaningful activities and social engagements are reduced.
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A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, 'I'm no good to anyone. I might as well be dead.' Which most therapeutic response should the nurse make to the client?
- A. You're not a useless person at all.'
- B. I'll ask the psychologist to see you about this.'
- C. You appear to be feeling pretty bad about things.'
- D. It makes me uncomfortable when you talk this way.'
Correct Answer: C
Rationale: Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication.
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching?
- A. I check my weight every day without fail.'
- B. I exercise 3 to 4 hours every day to keep my slim figure.'
- C. I've been told that I am 10% below my ideal body weight.'
- D. My best friend was in the hospital with this disorder a year ago.'
Correct Answer: B
Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being.
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
- A. I can understand what you mean. I'd be nervous too if I were in your shoes.
- B. This surgery is so successful that I wouldn't be concerned at all if I were you.
- C. Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.
- D. Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens.
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.
A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at her follow-up appointment?
- A. Focusing on the client's physical needs
- B. Encouraging the client to verbalize her feelings about the loss
- C. Reminding the client that she will be able to become pregnant again
- D. Encouraging the client to think of herself, her husband, and their future
Correct Answer: B
Rationale: The most therapeutic nursing intervention for a client recovering from multiple spontaneous abortions is to encourage the client to verbalize her feelings about the loss. This allows the client to express and process her emotions, facilitating the grieving process and emotional healing. Focusing solely on the client's physical needs, as in choice A, overlooks the importance of addressing the emotional aspect of the client's experience. Choice C, reminding the client that she will be able to become pregnant again, fails to acknowledge the current loss and may minimize the client's feelings of grief. Choice D, encouraging the client to think of herself, her husband, and their future, does not directly address the client's immediate emotional needs related to the recent loss. Therefore, choice B is the most appropriate intervention to support the client in coping with her emotional distress.
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.