Nokea
Which parameter would be assessed to determine the degree of anxiety being experienced by the client?
- A. Memory state
- B. Creativity level
- C. Perceptual field
- D. Delusional system
Correct Answer: C
Rationale: The correct parameter to assess the degree of anxiety experienced by a client is the perceptual field. As anxiety increases, perceptual fields tend to narrow. Memory state, creativity level, and delusional system are not directly related to the level of anxiety and are not appropriate parameters for determining the degree of anxiety. Memory state refers to the ability to remember, creativity level to the ability to generate new ideas or solutions, and delusional system to a set of false beliefs.
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A client diagnosed with angina pectoris is extremely anxious after being hospitalized. Which should the nurse do to minimize the client's anxiety?
- A. Provide care choices to the client.
- B. Keep the door open and the hallway lights on at night.
- C. Encourage the client to limit visitors to as few as possible.
- D. Arrange for the client to share a room with a cognitively alert client.
Correct Answer: A
Rationale: General interventions to minimize anxiety in the hospitalized client include providing information, social support, and control over choices related to care, as well as acknowledging the client's feelings. Leaving the door open with the hallway lights on may keep the client oriented, but these actions may interfere with sleep and increase anxiety. Limiting visitors reduces social support. The sharing of a room may not necessarily meet the client's needs.
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, 'I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing.' Which most therapeutic response should the nurse make to the client?
- A. I can understand what you mean. I'd be nervous too if I were in your shoes.
- B. This surgery is so successful that I wouldn't be concerned at all if I were you.
- C. Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.
- D. Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens.
Correct Answer: C
Rationale: Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client.
A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at her follow-up appointment?
- A. Focusing on the client's physical needs
- B. Encouraging the client to verbalize her feelings about the loss
- C. Reminding the client that she will be able to become pregnant again
- D. Encouraging the client to think of herself, her husband, and their future
Correct Answer: B
Rationale: The most therapeutic nursing intervention for a client recovering from multiple spontaneous abortions is to encourage the client to verbalize her feelings about the loss. This allows the client to express and process her emotions, facilitating the grieving process and emotional healing. Focusing solely on the client's physical needs, as in choice A, overlooks the importance of addressing the emotional aspect of the client's experience. Choice C, reminding the client that she will be able to become pregnant again, fails to acknowledge the current loss and may minimize the client's feelings of grief. Choice D, encouraging the client to think of herself, her husband, and their future, does not directly address the client's immediate emotional needs related to the recent loss. Therefore, choice B is the most appropriate intervention to support the client in coping with her emotional distress.
A neonatal intensive care nurse is caring for a newborn with a suspected diagnosis of erythroblastosis fetalis. Which therapeutic statement should the nurse make to the parents at this time?
- A. Your infant is very sick. The next 24 hours are the most crucial.'
- B. This is a common neonatal problem, so the prognosis is very good.'
- C. You have reason to worry but we have everything needed to care for your baby right here in this hospital.'
- D. You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care.'
Correct Answer: D
Rationale: The nurse should use therapeutic communication to address the parents' concerns and provide an opportunity for them to ask questions about their infant's care. Option 4 encourages open dialogue and supports the parents emotionally, which is critical during this stressful time. Option 1 may heighten anxiety without offering constructive support. Option 2 inaccurately minimizes the severity of erythroblastosis fetalis. Option 3 acknowledges worry but focuses on hospital resources rather than addressing the parents' emotional needs directly.
Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.
- A. Emotional: room coldness
- B. Environmental: boredom
- C. Physical: pain
- D. Communication: silence
Correct Answer: C
Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.