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When assessing a client with amyotrophic lateral sclerosis (ALS), the nurse should expect which of the following findings?
- A. Mental confusion
- B. Muscular weakness
- C. Sensory loss
- D. Emotional lability
Correct Answer: B
Rationale: ALS causes progressive muscular weakness and wasting, while cognitive function and sensory abilities remain intact, though grieving may occur.
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The nurse is teaching a client about the use of Rifampin for prophylaxis after an exposure to meningitis. What change in bodily functions should the nurse advise the client about?
- A. The client's urine might turn blue
- B. The client remains infectious to others for 48 hours
- C. The client's contact lenses might be stained orange
- D. The client's skin might take on a crimson glow
Correct Answer: C
Rationale: Rifampin causes orange discoloration of body fluids, which can permanently stain soft contact lenses, requiring client education to prevent concern or damage.
A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: The correct answer is denial. In this scenario, the client's statement indicates denial, which is a common reaction in Kübler-Ross's Stages of Grieving. Denial involves the refusal to accept or believe that a loss, such as a terminal illness diagnosis, is happening. Choices B, C, and D are incorrect: Anger involves feelings of resentment or frustration; Bargaining is an attempt to negotiate or make deals to avoid the situation; Acceptance is the final stage where the individual comes to terms with the reality of the situation.
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:
- A. immediately contact child protective services
- B. provide the mother with literature about child care
- C. consult a therapist to help the mother work out her fears
- D. refer the mother to parenting classes
Correct Answer: D
Rationale: Prevention of child abuse is centered on teaching parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents' social contacts and teach about community resources. Contacting child protective services (Choice A) is not appropriate in this scenario as there is no indication of abuse or neglect. Providing literature (Choice B) may not be as effective as parenting classes in addressing the mother's concerns. Consulting a therapist (Choice C) may be beneficial for underlying mental health issues, but parenting classes specifically focus on child care and coping skills, making Choice D the most suitable option in this situation.
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct Answer: C
Rationale: Explanation: Ashley is displaying symptoms of severe anxiety, including confusion, trouble focusing, dizziness, nausea, rapid pulse, and hyperventilation. These somatic symptoms, along with changes in vital signs, indicate severe anxiety. In severe anxiety, individuals are unable to solve problems and have a poor grasp of their environment. On the other hand, mild anxiety may lead to mild discomfort or even enhanced performance, while moderate anxiety results in difficulty grasping information and minor changes in vital signs. Panic, the most severe level of anxiety, involves markedly disturbed behavior and a potential loss of touch with reality. Therefore, based on Ashley's symptoms, her anxiety level should be assessed as severe.
All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence
- B. desire to maintain authority
- C. confidence in subordinate
- D. getting trapped in the 'I can do it better myself' mindset
Correct Answer: C
Rationale: If a delegator has confidence in their subordinates and believes a task will be performed correctly, they are more likely to delegate. Reasons nurses may be reluctant to delegate include their own lack of self-confidence, the desire to maintain authority, and getting trapped in the 'I can do it better myself' mindset. Therefore, 'confidence in subordinate' is the exception as it actually encourages delegation. The other choices are common barriers to delegation in healthcare settings.