Nokea
Which statement by an 8-year-old girl, who was just admitted to the hospital, needs to be explored?
- A. Wow! This hospital has bright colors.''
- B. Is my mother allowed to visit me tonight?'
- C. Those boys are so cute. I hope their room is next to mine!'
- D. I'm scared about being here. Can you stay with me awhile?'
Correct Answer: C
Rationale: The correct answer is C. An 8-year-old child showing a strong attraction to boys at this age may raise concerns about precocious sexual behavior or exposure to inappropriate sexual content, potentially signaling the need to investigate for possible sexual abuse. It is important to explore this statement further. Choice A, expressing admiration for bright colors, is a common behavior for children of this age and does not raise immediate concerns. Choice B, inquiring about the mother's visit, is a typical concern for a hospitalized child seeking comfort and support. Choice D, expressing fear and seeking reassurance from the nurse, is also a normal reaction for an 8-year-old in a new and possibly intimidating environment. However, the statement in Choice C stands out as it deviates from age-appropriate behavior and warrants further exploration to ensure the child's safety and well-being.
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Which basic principle of Alcoholics Anonymous (AA) should a client with alcohol use disorder follow?
- A. Spouses should attend Al-Anon meetings.
- B. It is a commitment to focus on long-term goals.
- C. Amends must be made to each person who has been harmed.
- D. People have the power to overcome alcoholism if they truly want to stop drinking.
Correct Answer: C
Rationale: The correct answer is that amends must be made to each person who has been harmed. This principle is reflected in the eighth step of the 12 steps of AA, which involves making a list of all persons harmed and being willing to make amends to them. It is a fundamental principle of AA to address past harms and seek to rectify them. Choice A is incorrect because spouses attending Al-Anon meetings is not a basic principle of AA; it is a support group for family members of individuals with alcohol use disorder. Choice B is incorrect because while focusing on long-term goals can be beneficial, AA emphasizes taking one day at a time rather than committing to long-term goals. Choice D is incorrect because AA teaches that individuals struggling with alcoholism are powerless over their addiction and need to rely on a higher power rather than solely their willpower to overcome it.
A client is discussing her problematic marital relationship with the nurse. Which statement by the nurse is an example of the nontherapeutic communication technique of giving reassurance?
- A. I think you should try marital counseling. I've had to do that myself once and it helped.
- B. Why don't you see a conflict resolution specialist? I can give you that information.
- C. I agree with you. He should not argue with you when he has problems at work that are not your fault.
- D. Everything will be okay if you talk to him about how it makes you feel.
Correct Answer: D
Rationale: Giving reassurance, such as saying 'Everything will be okay,' is nontherapeutic because it dismisses the client's concerns and may minimize their feelings without addressing the underlying issue.
A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions, the client says, 'That sounds gross. I don't think I can do it.' Which conclusion would the nurse make from this statement?
- A. The client is unduly fastidious.
- B. The client feels that having a baby is not that important.
- C. The client may be uncomfortable with performing manual examination of the genitals.
- D. The client is afraid that she is the cause of the infertility.
Correct Answer: C
Rationale: The client's statement expressing discomfort with the procedure indicates a potential unease with performing a manual examination of her genitals. It is not uncommon for individuals to feel uncomfortable or anxious about such intimate procedures. The nurse should explore this further with the client to address any concerns or fears. The option stating that the client is unduly fastidious lacks evidence and is not supported by the client's statement. The assumption that the client does not value having a baby is not warranted based on the given statement. While self-blame is a common emotional response in cases of infertility, the client's statement does not directly suggest this as the primary concern in this scenario.
Which intervention does the nurse include in the plan of care for a client from a different culture?
- A. Being respectful of the client's needs.
- B. Expecting non-adherent behavior.
- C. Monitoring for difficulty with dietary restrictions.
- D. Offering a firm handshake upon leaving the client.
Correct Answer: A
Rationale: Respecting the client's cultural needs promotes trust and effective care, ensuring culturally sensitive interventions. Expecting non-adherence is biased, monitoring dietary restrictions is too specific, and a handshake may not be culturally appropriate.
The nurse is caring for a client who is taking tricyclic antidepressants. Which statement by the client indicates that the medication is working properly?
- A. I haven't felt like going to work this week.
- B. I've joined a bridge club in my neighborhood.
- C. I sleep 12 hours a night and take a nap during the day.
- D. I have felt my heart racing since I started the medicine.
Correct Answer: B
Rationale: Joining a social activity like a bridge club indicates improved mood and engagement, a sign that the antidepressant is effective.