Nokea
Which nursing action is most appropriate in this situation?
- A. Asking the client why he or she is so suspicious
- B. Putting the chart away
- C. Handing the client the form to read
- D. Telling the client that it is illegal to read the client record
Correct Answer: B
Rationale: Putting the chart away maintains privacy without escalating suspicion.
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On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.
If the adolescent who is involved in gang activities demonstrates the following behaviors during group meetings, which is most indicative of resistance to therapy?
- A. The adolescent borrows cigarettes from others.
- B. The adolescent laughs inappropriately.
- C. The adolescent keeps checking the clock.
- D. The adolescent fidgets in the chair.
Correct Answer: B
Rationale: Inappropriate laughter suggests discomfort or dismissal of the therapeutic process.
If this child is typical of others the same age with a serious illness, which concept is the most commonly held belief about being ill?
- A. Illness is not life-threatening; recovery is assured.
- B. Significant others can prevent serious consequences.
- C. Illness is a punishment for some wrong-doing.
- D. Failure to comply with treatment results in parental rejection.
Correct Answer: C
Rationale: School-age children often view illness as punishment due to magical thinking.
The nurse correctly explains that this client's behavior is an example of which psychological defense mechanism?
- A. Displacement
- B. Regression
- C. Denial
- D. Compensation
Correct Answer: C
Rationale: Seeking contraception while suspecting pregnancy reflects denial of the reality.
What is the best suggestion the nurse can give the nursing assistant caring for the 2-year-old child at this time?
- A. Let the child choose from two acceptable alternatives.
- B. Withhold something the child desires until the child complies.
- C. Identify what is expected of the child, rather than ask.
- D. Inform the mother if the child continues to be uncooperative.
Correct Answer: A
Rationale: Offering choices fosters autonomy while maintaining boundaries.