Nokea
Which of the following symptoms should a nurse expect to assess in a client experiencing elevated levels of thyroid hormone? Select all that apply.
- A. Emotional lability
- B. Depression
- C. Insomnia
- D. Restlessness
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Elevated levels of thyroid hormone can lead to increased emotional reactivity and mood swings. This is due to the impact of thyroid hormone on neurotransmitters in the brain. Depression (B) is more commonly associated with low thyroid hormone levels. Insomnia (C) can occur with both high and low thyroid hormone levels. Restlessness (D) is more indicative of hyperthyroidism, where there is excess thyroid hormone.
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Which is the most significant consequence of the excessive use of defense mechanisms?
- A. Emotions will be experienced intensely.
- B. Problem-solving will be limited.
- C. The superego will be suppressed.
- D. Learning and the ability to grow will be enhanced.
Correct Answer: B
Rationale: The correct answer is B because excessive use of defense mechanisms can hinder problem-solving skills by avoiding facing reality and finding constructive solutions. Defense mechanisms are psychological strategies that individuals unconsciously use to cope with anxiety and protect the ego. By relying too heavily on these mechanisms, individuals may overlook important issues, leading to limited problem-solving abilities. This can result in difficulties in adapting to challenges and impede personal growth. Emotions being experienced intensely (A) is not the most significant consequence as it is a natural response to certain situations and does not directly relate to defense mechanisms. The superego being suppressed (C) is not a direct consequence of defense mechanisms but may occur as a result of unresolved conflicts. Learning and growth being enhanced (D) is incorrect as excessive defense mechanisms can actually hinder learning and personal development.
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
- A. History of alcohol dependence
- B. History of personality disorder
- C. History of schizophrenia
- D. History of hypertension
Correct Answer: A
Rationale: The correct answer is A: History of alcohol dependence. Alprazolam is a benzodiazepine and can be addictive, especially for individuals with a history of substance abuse like alcohol dependence. This client population is at higher risk for misuse, addiction, and overdose. It is important for the nurse to question this order to avoid potential harm. Choices B, C, and D are incorrect as they do not directly impact the safety or efficacy of alprazolam for acute anxiety.
A client is trying to explore and solve a problem. Which nursing statement would be an example of verbalizing the implied?
- A. You seem to be motivated to change your behavior.
- B. How will these changes affect your family relationships?
- C. Why dont you make a list of the behaviors you need to change.
- D. The team recommends that you make only one behavioral change at a time.
Correct Answer: A
Rationale: Step 1: A is correct as it reflects active listening and shows empathy towards the client.
Step 2: By stating "You seem to be motivated to change your behavior," the nurse acknowledges the client's feelings and encourages further exploration.
Step 3: This statement helps the client feel understood and supported in their journey towards change.
Summary:
B: Focuses on family relationships, not the client's motivation.
C: Suggests a directive approach rather than exploring the client's feelings.
D: Imposes a specific recommendation without considering the client's readiness or motivation.
A nurse should provide this information to facilitate which ethical principle?
- A. Autonomy
- B. Beneficence
- C. Nonmaleficence
- D. Justice
Correct Answer: A
Rationale: The correct answer is A: Autonomy. Autonomy refers to respecting an individual's right to make informed decisions about their own care. Providing information empowers patients to make autonomous decisions, aligning with this principle. Beneficence focuses on doing good for the patient, nonmaleficence on avoiding harm, and justice on fairness in resource allocation. While these are important ethical principles in healthcare, they do not directly relate to the act of providing information to support patient autonomy.
A Native American client is admitted to an emergency department (ED) with an ulcerated toe secondary to uncontrolled diabetes mellitus. The client refuses to talk to a physician unless a shaman is present. Which nursing intervention is most appropriate?
- A. Assist the client in contacting a shaman of his choice.
- B. Explain to the client that voodoo medicine will not heal the ulcerated toe.
- C. Ask the client to explain what the shaman can do that the physician cannot.
- D. Inform the client that refusing treatment is a clients right.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Cultural Competence: In respecting the client's cultural beliefs and practices, it is essential to honor the request for a shaman's presence.
2. Collaboration: By assisting the client in contacting a shaman, the nurse promotes collaboration between traditional healing methods and medical interventions.
3. Trust Building: Respecting the client's request fosters trust and rapport, which are crucial for effective communication and care.
4. Patient-Centered Care: This approach aligns with the principle of patient-centered care, where the client's preferences and values are prioritized.
Summary of Other Choices:
B: This choice is dismissive and disrespectful of the client's beliefs, potentially causing harm by undermining trust and rapport.
C: This choice puts the client on the defensive and does not address the immediate need for a shaman's presence.
D: This choice fails to address the client's request and focuses on the right to refuse treatment, which is not the immediate concern in