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When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?
- A. Listen to the parents' description of the child's behavior.
- B. Compare the child's function from one occasion to another.
- C. Engage the parents in a discussion about the child's feelings.
- D. Determine the child's mental status through direct questioning.
Correct Answer: B
Rationale: To accurately assess the mental status of a young school-aged child, it is crucial for the nurse to compare the child's function over time. This approach allows for a more objective evaluation of the child's mental status. While listening to the parents' description of the child's behavior can provide valuable insights, it may be biased and subjective. Engaging parents in discussions about the child's feelings is important for overall understanding but may not directly assess the child's mental status. Directly questioning the child about their mental status can be threatening and may lead to anxiety, making it a less optimal approach compared to observing and comparing the child's function over time.
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Which initial response would the nurse make to a 67-year-old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have an erection for several years?
- A. At your age, sex isn't that important.''
- B. That is a natural occurrence at your age.''
- C. You sound upset about not being able to have an erection.''
- D. Maybe it's time for you to speak to your primary health care provider about this.''
Correct Answer: C
Rationale: The correct response is, 'You sound upset about not being able to have an erection.' When a client discloses personal information, the nurse should respond in a non-judgmental manner to encourage further communication and gather more details. This response demonstrates empathy and understanding, opening the door for the patient to express his feelings and concerns. Choice A, 'At your age, sex isn't that important,' is dismissive and fails to address the client's emotions or concerns, potentially hindering open communication. Choice B, 'That is a natural occurrence at your age,' provides inaccurate information as the inability to have an erection is not considered a normal part of aging. Choice D, 'Maybe it's time for you to speak to your primary health care provider about this,' while important eventually, should not be the initial response as the nurse should first explore the client's feelings and concerns before discussing potential referrals or interventions.
The nurse is caring for a client who is taking tricyclic antidepressants. Which statement by the client indicates that the medication is working properly?
- A. I haven't felt like going to work this week.
- B. I've joined a bridge club in my neighborhood.
- C. I sleep 12 hours a night and take a nap during the day.
- D. I have felt my heart racing since I started the medicine.
Correct Answer: B
Rationale: Joining a social activity like a bridge club indicates improved mood and engagement, a sign that the antidepressant is effective.
The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate?
- A. The client's use of language.
- B. The client's insight into the depression.
- C. The client's socialization history and skills.
- D. The client's attitude toward medications.
Correct Answer: B
Rationale: Cognitive therapy focuses on thought patterns and self-awareness. Evaluating the client's insight into their depression is critical to assess their understanding of their condition and tailor therapy effectively. Other aspects are less directly tied to cognitive approaches.
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.
A client diagnosed with cancer is placed on permanent total parenteral nutrition as a means of providing nutrition. Which is the rationale for the nurse to include psychosocial support when planning care for this client?
- A. Death is imminent.
- B. The client will need to adjust to the idea of living without eating by the usual route.
- C. Total parenteral nutrition requires disfiguring surgery for permanent port implantation.
- D. Nausea and vomiting occur regularly with this type of treatment and will prevent the client from participating in social activity.
Correct Answer: B
Rationale: Permanent total parenteral nutrition is indicated for clients who can no longer absorb nutrients via the enteral route. These clients will no longer take nutrition orally. The remaining options are inaccurate. There is no indication in the question that death is imminent. Permanent port implantation is not disfiguring. Total parenteral nutrition does not cause nausea and vomiting.