Nokea
Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?
- A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
- B. A client reads a story about a traumatic event and then visualizes the result
- C. A client focuses on a negative thought in their mind while tapping their fingers
- D. None of the above
Correct Answer: A
Rationale: Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.
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One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?
- A. You may not have enough energy before long to hold a big party.'
- B. Do you mean to say that you want to plan your funeral and wake?'
- C. Planning a party and thinking about all your friends sounds like fun.'
- D. You should be thinking about spending your last days with your family.'
Correct Answer: C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
- A. Record the amount on the client's fluid output record.
- B. Encourage the client to increase oral fluid intake.
- C. Notify the healthcare provider of the findings.
- D. Palpate the client's bladder for distention.
Correct Answer: A
Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
- A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
- B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
- C. Assist the client to a standing position by gently lifting upward from underneath the axillae.
- D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Correct Answer: B
Rationale: Option B is the correct procedure for assisting a client from the bed to a chair. By positioning the nurse's feet apart and aligning the knees with the client's knees, the nurse maintains a stable base of support while pivoting the client into the chair. This technique minimizes the risk of injury to both the nurse and the client. Placing the chair at a 45-degree angle to the bed, with the back of the chair toward the head of the bed, provides a clear path for the client to move. Option C is incorrect because lifting a client under the axillae can potentially cause nerve damage and strain. Option D is also incorrect as it involves an unsafe method of moving the client and can lead to injuries or accidents.
What step should be taken when administering ear drops to an adult client?
- A. Place the client in a side-lying position.
- B. Hold the dropper 1 cm above the ear canal.
- C. Place a cotton ball into the outermost canal.
- D. Pull the auricle down and back.
Correct Answer: A
Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (½ inch) above the ear canal (B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.
The mother of a 5-month-old is being educated about her baby's nutrition by the nurse. Which statement by the mother indicates the need for further teaching?
- A. I'm going to try feeding my baby some rice cereal.''
- B. When he wakes at night for a bottle, I feed him.''
- C. I dip his pacifier in honey so he'll take it.''
- D. I keep formula in the refrigerator for 24 hours.''
Correct Answer: C
Rationale: The correct answer is ''I dip his pacifier in honey so he'll take it.'' This statement indicates a need for further teaching because honey should be avoided in infants due to the risk of infant botulism. Honey may contain spores of Clostridium botulinum, which can lead to serious illness in infants as they lack the necessary digestive enzymes to eliminate the spores. Feeding rice cereal, responding to night-time feedings, and storing formula in the refrigerator are appropriate practices for infant care, indicating understanding of the instructions.