Nokea
Which of the following services is not part of family consultation?
- A. assisting with vocational rehabilitation
- B. providing information about the client's illness
- C. teaching effective communication
- D. helping families solve problems
Correct Answer: A
Rationale: Family consultation does not involve vocational rehabilitation. It involves helping families deal with their feelings, focus, and find solutions. Choices 2, 3, and 4 are components of family consultation.
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A client is 36 hours post-op a TKR surgery, 270 cc's of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
- A. Notify the doctor
- B. Empty the drain
- C. Do nothing
- D. Remove the drain
Correct Answer: A
Rationale: The physician should be notified if excessive drainage is noted from the surgical site.
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct Answer: C
Rationale: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what's happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality.
Which of the following viruses is most likely to be acquired through casual contact with an infected individual?
- A. influenza virus
- B. herpes virus
- C. cytomegalovirus (CMV)
- D. human immunodeficiency virus (HIV)
Correct Answer: A
Rationale: Influenza virus is transmitted through respiratory droplets. Herpes virus is transmitted by direct contact, and HIV is transmitted through blood and body fluids. Cytomegalovirus is an opportunistic infection.
During the work phase of the nurse-client relationship, the client says to her primary nurse, 'You think that I could walk if I wanted to, don't you?' What is the best response by the nurse?
- A. Yes, if you really wanted to, you could.
- B. Tell me why you're concerned about what I think.
- C. Do you think you could walk if you wanted to?
- D. I think you're unable to walk now, whatever the cause.
Correct Answer: D
Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client's self-esteem. Choice 1 is an open and candid response but diminishes the client's self-esteem. Choice 2 doesn't answer the client's question and is not helpful. Choice 3 increases the client's anxiety because her inability to walk might be directly related to an unconscious psychological conflict that has not been resolved.
Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens's concerns is likely to predominate?
- A. Will my retirement funds outlast me?
- B. Who will handle my funeral arrangements?
- C. What will become of Jonathan when I am gone?
- D. How can I get Jonathan's physician to talk to me?
Correct Answer: C
Rationale: The mother's most prominent concern is likely to be what becomes of her son after she dies. Choice 1 is important but is not likely to be her most prominent concern. Choice 2 is also not likely to be her primary concern because the welfare of her son with schizophrenia is more important. Choice 4 is incorrect because Mrs. Owens has likely confronted and handled concerns about getting the physician to talk to her after 38 years of managing her son's care.