Nokea
Which of the following is a symptom associated with sensory overload?
- A. Disorientation
- B. Drowsiness
- C. Emotional lability
- D. Depression
Correct Answer: A
Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.
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A female nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is most important for the nurse to intervene if she takes which action?
- A. The nurse explains the 0 to 10 intensity pain scale.
- B. The nurse asks the patient when the headaches started.
- C. The nurse sits down at the bedside and closes the privacy curtain.
- D. The nurse calls for a male nurse to bring a hospital gown to the room.
Correct Answer: C
Rationale: In some Arab cultures, it is not considered appropriate for a male to be alone with a female who is not his spouse. Therefore, it is important for the nurse to respect the patient's cultural beliefs and privacy by ensuring that a female nurse is not alone with the male patient. Sitting down at the bedside and closing the privacy curtain could potentially lead to a situation where the nurse is alone with the patient, which goes against the patient's cultural norms. The other actions, such as explaining the pain scale, asking about the onset of headaches, and requesting a male nurse to bring a hospital gown, are all appropriate and do not conflict with the patient's cultural beliefs.
A client says, 'The doctors lied about me. They said I murdered my mother. You killed her. She died before I was born.' Which psychotic feature is the client experiencing?
- A. Ideas of grandeur
- B. Confusing illusions
- C. Persecutory delusions
- D. Auditory hallucinations
Correct Answer: C
Rationale: The client is experiencing persecutory delusions, as she believes that others are blaming her for negative actions. This is not about ideas of grandeur, which involve feelings of greatness or power. Confusing illusions refer to misinterpretation of stimuli, which is not present in this scenario. Auditory hallucinations involve hearing voices, which is not the case here. In this case, the client is delusional, but not hallucinating.
After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that both she and her partner are visibly upset and crying. Which statement would be a therapeutic response?
- A. 'I'll be here if you want to talk.''
- B. 'Try to relax"?it'll speed up the healing process.''
- C. 'With any luck, you'll get pregnant again soon.''
- D. 'It's best that this happened early rather than having the baby die after it was born.''
Correct Answer: A
Rationale: A therapeutic response in this situation is to offer support and empathy. Saying, 'I'll be here if you want to talk' gives the client and her partner the opportunity to express their emotions and seek comfort. It acknowledges their distress and assures them of the nurse's availability. Choice B, advising to relax to speed up the healing process, dismisses their current emotions and may hinder open communication. Choice C, suggesting getting pregnant again soon, minimizes their grief over the loss and may not be what the couple needs to hear at that moment. Choice D, stating it's best that the miscarriage happened early, is insensitive as it invalidates the couple's feelings of loss and grief. Grieving is a natural process, and the timing of the loss does not diminish its significance.
A client decides to have hospice care rather than undergo an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?
- A. Justice
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: C
Rationale: The correct answer is 'Autonomy.' Autonomy refers to an individual's right to make decisions about their own care. In this scenario, the client is choosing hospice care over surgery, demonstrating their autonomy in making healthcare choices. Justice involves fairness and equality in the distribution of resources and services, which is not the primary ethical principle illustrated in this case. Veracity pertains to truthfulness and honesty, which is not directly related to the client's decision-making process. Beneficence refers to the duty to do good and act in the best interest of the patient, which is not the central ethical principle demonstrated by the client's decision for hospice care.
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?
- A. "I don't remember anything about what happened to me."?
- B. "I'd rather not talk about it right now."?
- C. "It's the other entire guy's fault! He was going too fast."?
- D. "My mother is heartbroken about this."?
Correct Answer: A
Rationale: The correct answer is, '"I don't remember anything about what happened to me."?' Suppression involves willfully putting an unacceptable thought or feeling out of one's mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '"I'd rather not talk about it right now,"?' suggests avoidance or deflection rather than active suppression. Choice C, '"It's the other entire guy's fault! He was going too fast,"?' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '"My mother is heartbroken about this,"?' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.