Nokea
Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?
- A. Tell me about the relationship that you have with your mother and father.''
- B. Hello! I'm Nurse Andrea. I'll introduce you around and help you settle in.''
- C. What is the main thing that you would like to work on during therapy?'
- D. I understand that you have been depressed. What can you tell me about that?'
Correct Answer: B
Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.
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A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behaviors indicate the client is emotionally accepting the impending death?
- A. Revising the client's will and planning a visit to a friend
- B. Alternating between crying and talking openly about death
- C. Seeking second, third, and fourth medical opinions
- D. Refusing to follow treatments and stating they won't help anyway
Correct Answer: A
Rationale: Revising the will and planning a visit to a friend are indicative of emotional acceptance of impending death as they demonstrate realistic, productive, and constructive ways of using the remaining time. Alternating between crying and talking openly about death may suggest depression rather than acceptance. Seeking multiple medical opinions shows disbelief, denial, or desperation rather than acceptance. Refusing treatments and stating they won't help reflects anger and hopelessness, not acceptance.
Which source of stress would the nurse anticipate in a 5-year-old client?
- A. Jealousy
- B. Stubbornness
- C. Procrastination
- D. Companionship
Correct Answer: C
Rationale: Procrastination, which refers to delaying completing chores or activities, is a common source of stress for 5-year-old clients. At this age, children may start experiencing stress related to the pressure of tasks or expectations. Jealousy and stubbornness are more typical sources of stress for 3- and 4-year-old clients who are still developing social and emotional skills. Companionship, on the other hand, is generally seen as a positive aspect in a child's life and is not typically a source of stress but rather a source of support and comfort.
Which activity would be most beneficial for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment?
- A. Wearing make-up
- B. Making up missed work
- C. Participating in sports activities
- D. Participating in creative activities
Correct Answer: B
Rationale: Making up missed work is an essential activity that can help a school-age client diagnosed with a chronic illness feel a sense of accomplishment. By catching up on missed work, the child can regain a sense of control and productivity, which can be empowering during a challenging time. Wearing make-up is more related to personal grooming and self-expression, which may not directly contribute to a sense of accomplishment in this context. Participating in sports activities is beneficial for peer relationships and physical health but may not address the immediate need for accomplishment in the academic setting. Engaging in creative activities fosters cognitive development but may not directly address the sense of achievement associated with completing academic tasks.
When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
- A. Tell me about your typical day before you were diagnosed with chronic lung disease.''
- B. Smoking and not doing the exercises will make your lung disease continue to get worse.''
- C. I can't make you stop doing what you are doing, and it's your choice to be sick or well.''
- D. Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct Answer: A
Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
According to Erikson's theory, which behavior would the nurse expect a preschooler to exhibit?
- A. The child develops the superego.
- B. The child plays beside other children.
- C. The child concentrates on work and play.
- D. The child becomes casual about body appearance.
Correct Answer: A
Rationale: According to Erikson's theory, a preschooler develops the superego or conscience during the initiative versus guilt stage. This stage occurs around ages 3 to 6 years old. The development of the superego is crucial for the child to start understanding and internalizing societal and parental values. Choice B is incorrect because playing beside other children typically occurs during the autonomy versus shame and doubt stage, which is seen in toddlers. Choice C is incorrect as concentrating on work and play is more characteristic of the industry versus inferiority stage, typically seen in school-aged children. Choice D is incorrect because becoming casual about body appearance is more aligned with the identity versus role confusion stage, which is seen in adolescents who have a marked preoccupation with appearance and body image.