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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A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor?
- A. Irrelevant
- B. Harm/loss
- C. Threatening
- D. Challenging
Correct Answer: D
Rationale: The correct answer is D: Challenging. The client's statement indicates a positive reframing of the job loss as an opportunity for personal growth. This suggests that the client views the situation as a challenge to adapt and pursue a new path. This perspective aligns with the concept of stress as a potential source of growth and development, known as the challenge appraisal.
Summary:
A: Irrelevant - The client's statement demonstrates relevance to his future plans, making this choice incorrect.
B: Harm/loss - The client's positive outlook does not reflect a perception of harm or loss, making this choice incorrect.
C: Threatening - The client's statement does not convey a perception of threat, making this choice incorrect.
When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, I dont drink too much!
Correct Answer: D
Rationale: The correct answer is D because the client is using denial as a defense mechanism to cope with the stress of being confronted about her alcohol abuse. By saying "I don't drink too much," she is refusing to acknowledge the reality of her excessive alcohol consumption. This denial allows her to avoid facing the uncomfortable truth and the need for change.
A: Hiding liquor bottles in a closet is an example of a defense mechanism called displacement, not denial.
B: Yelling at their son for slouching in his chair is an example of a defense mechanism called projection, not denial.
C: Burning dinner on purpose is an example of a defense mechanism called passive-aggression, not denial.
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
Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
- A. The employee assertively confronts the boss
- B. The employee leaves the staff meeting to work out in the gym
- C. The employee criticizes a coworker
- D. The employee takes the boss out to lunch
Correct Answer: C
Rationale: Displacement is a defense mechanism where emotions are redirected from the original source to a substitute target. In this case, the employee is likely to displace their anger from the boss onto a coworker by criticizing them. This behavior allows the employee to express their feelings indirectly.
A: Assertively confronting the boss does not align with displacement as it involves direct confrontation.
B: Leaving the meeting to work out in the gym is a form of avoidance and does not involve displacing emotions onto another target.
D: Taking the boss out to lunch is more of a conciliatory gesture and does not involve displacing negative emotions onto someone else.