Nokea
Which instruction should the nurse provide to a preschool-age client to prevent altered growth and development?
- A. Trust
- B. Empathy
- C. Impulse control
- D. Problem-solving
Correct Answer: C
Rationale: Teaching a preschool-age child and their parents about the importance of impulse control is essential to prevent the risk of altered growth and development. Preschool-age children are at a stage where they are developing self-regulation skills, so teaching them to manage their impulses can help in their overall growth and development. Trust is a critical concept taught during infancy to foster secure attachments. Empathy is crucial for parents of toddlers to understand their child's emotions. Problem-solving skills are typically emphasized for school-age children to enhance cognitive development.
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The nurse is observing the parents at the bedside of their small-for-gestational-age (SGA) infant, who was born at 27 weeks' gestation. The infant's mother states, 'She is so tiny and fragile. I'll never be able to hold her with all those tubes.' Considering this statement, which concern should the nurse identify for the mother?
- A. Impaired adjustment
- B. Trouble with family coping
- C. Potential for compromised parenting
- D. Difficulty understanding health concerns
Correct Answer: C
Rationale: Parents of a high-risk neonate, such as a preterm SGA infant, are at risk for compromised parenting. Parent-infant bonding is affected if the infant does not exhibit normal newborn characteristics. Option 1 involves the nonacceptance of a health status change or an inability to solve a problem or set a goal. Option 2 involves the identification of trouble with family coping. Option 4 addresses the condition's characteristics.
A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, 'I feel like I've lost my sense of power.' Which response would the nurse give?
- A. Hair does not empower a person.'
- B. Losing power seems important to you.'
- C. Knowledge is power; I'll give you some pamphlets to read.'
- D. Hair loss is common; it will grow back, so you should not worry.'
Correct Answer: B
Rationale: The correct response is, 'Losing power seems important to you.' This response acknowledges the client's feelings and provides an opportunity for further discussion. Choice A is confrontational and dismissive, potentially shutting down communication. Choice C offers pamphlets, which may be seen as dismissing the client's concerns and avoiding engaging in a conversation. Choice D minimizes the client's feelings and may discourage further expression of emotions. By choosing option B, the nurse shows empathy and encourages the client to explore their emotions in a supportive environment.
A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?
- A. Stay at the bedside with the family and the deceased.
- B. Direct activities related to funeral arrangements.
- C. Mobilize the support systems for the family.
- D. Present the full reality of the loss to the family.
Correct Answer: A
Rationale: During the shock phase of a grief reaction, the hospice nurse's initial intervention should be to stay at the bedside with the family and the deceased. This action provides immediate support to the family until coping mechanisms and personal support systems can be mobilized. Directing activities related to funeral arrangements is not within the nurse's role and responsibility. Mobilizing the support systems for the family is important, but staying with the family and the deceased helps in providing immediate comfort and support. Presenting the full reality of the loss to the family is not appropriate during the shock phase as acceptance of the loss takes time and is not the immediate priority.
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.
What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?
- A. Feelings of guilt
- B. Need to control others
- C. Desire for punishment
- D. Excessive physical activity
Correct Answer: D
Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.