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What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?
- A. Scheduling pain medication at regular intervals
- B. Administering the medication only when the pain is severe
- C. Avoiding the administration of medication unless it is requested
- D. Recognizing that less pain medication will be needed by this client compared with other women in labor
Correct Answer: A
Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.
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Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment?
- A. Continual pacing
- B. Suspicious feelings
- C. Inability to socialize with others
- D. Disturbed relationship with the family
Correct Answer: B
Rationale: In the early phase of treatment for a client with schizophrenia, the nurse needs to address the client's suspicious feelings to establish trust and create a therapeutic environment. Suspicious feelings can hinder the development of a positive nurse-client relationship. Continual pacing, while a symptom, can be managed by the nurse and does not directly impact the therapeutic relationship. Inability to socialize with others and a disturbed relationship with the family are important factors but are of lesser concern in the early treatment phase as compared to addressing suspicious feelings to build trust and rapport.
When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?
- A. Increase in pulse rate
- B. Widened pulse pressure
- C. Increase in body temperature
- D. Decrease in diastolic blood pressure
Correct Answer: B
Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.
The nurse is caring for a dying client who states, 'Will you be the executor of my will?' How should the nurse best respond to this client?
- A. I must decline your offer because I am your nurse.
- B. I will carry out your will according to your wishes.
- C. It is an honor to be named the executor of your will.
- D. Tell me more so that I can understand your thinking.
Correct Answer: D
Rationale: The client's question reflects his thoughts about the will and how to obtain an executor, but the question does not reveal why the client is asking the nurse to be executor, and it also does not address other important information. In option 4, the nurse seeks clarification while acknowledging the client's statement. Most agencies do not allow the nurse to be the executor of a client's will (option 3). The other options fail to regard the potential consequences, think critically, or explore the client's motivation and needs.
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.
Which parameter would be assessed to determine the degree of anxiety being experienced by the client?
- A. Memory state
- B. Creativity level
- C. Perceptual field
- D. Delusional system
Correct Answer: C
Rationale: The correct parameter to assess the degree of anxiety experienced by a client is the perceptual field. As anxiety increases, perceptual fields tend to narrow. Memory state, creativity level, and delusional system are not directly related to the level of anxiety and are not appropriate parameters for determining the degree of anxiety. Memory state refers to the ability to remember, creativity level to the ability to generate new ideas or solutions, and delusional system to a set of false beliefs.