Nokea
While in the dining area, an adult client at the retirement center yells, 'This turkey is dry and cold! I can't stand the food here!' Which is the best response by the nurse to the client's behavior?
- A. Now look what you've done! You're ruining this meal for the whole community. Aren't you ashamed of yourself?
- B. I think you had better return to your apartment now. I'll make arrangements for a new meal to be served to you there.
- C. Let me get you another serving that is more to your liking. Would you like to see the chef and select your own serving?
- D. One of the things that was agreed upon was that anyone who did not use appropriate behavior would be asked to leave the dining room. Please leave now.
Correct Answer: C
Rationale: Asking the client to accompany the nurse to the kitchen respects the client's need for control, removes the angry client from the dining room, and may offer the nurse an opportunity to assess what is happening with the client. Agency procedure should be followed regarding those who are allowed access to the facility kitchen. Option 1 is angry, aggressive, and nontherapeutic. Option 2 could provoke a regressive struggle between the nurse and the client and cause more anger in the client. In option 4, the nurse is authoritative, and it would not be appropriate to ask the client to leave. This action may set up an aggressive struggle between the nurse and the client.
You may also like to solve these questions
A client experiencing urticaria (hives) and pruritus states to the nurse, 'What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy.' Which statement made by the nurse is the most therapeutic?
- A. You're troubled that this will extend into your wedding?
- B. It's probably just due to prewedding jitters. You'll be fine.
- C. The antihistamine will help a great deal, just you wait and see.
- D. Do you think this would really be something that could ruin your wedding?
Correct Answer: A
Rationale: The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety and fears. In option 3, the nurse talks about antihistamines and asks the client to 'wait and see.' This is nontherapeutic because the nurse is making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4, the nurse responds without sensitivity.
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.
During the nursing assessment, the client states, 'My surgeon just told me that my cancer has spread, and I have less than 6 months to live.' Which nursing response would be the most therapeutic?
- A. I am sorry. Would you like to discuss this with me some more?'
- B. I am sorry. There are no easy answers in times like this, are there?'
- C. I hope you'll focus on the fact that your doctor says you have 6 months to live and that you'll think of how you'd like to live.'
- D. I know it seems desperate, but there have been a lot of breakthroughs. Something might come along in a month or so to change your status drastically.'
Correct Answer: A
Rationale: The client has received very distressing news and is most likely still experiencing shock and denial. In option 1, the nurse invites the client to ventilate feelings. Option 2 is social and expresses the nurse's feelings rather than the client's feelings. Option 3 is patronizing and stereotypical. Option 4 provides social communication and false hope.
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
- A. The process of grief is detrimental to physical and emotional health.
- B. Age, gender, and culture are a few factors that influence the grieving process.
- C. The nurse must explore his own feelings about death before he may effectively help others.
- D. The nurse should discourage expression of grief and loss because it may upset other clients nearby.
- E. The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one.
Correct Answer: B,C,E
Rationale: Grief is influenced by age, gender, and culture (B), nurses must process their own feelings about death (C), and helping families cope with loneliness/depression (E) is appropriate. Grief is not inherently detrimental (A), and discouraging expression (D) is counterproductive.
A preschool child is placed in traction for a femur fracture. The child has started bedwetting, even though the child has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation?
- A. A body image disturbance
- B. Attention-seeking behavior
- C. Opposition to authority figures
- D. Regressing to earlier developmental behavior
Correct Answer: D
Rationale: The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children, and they usually do not require professional intervention. Body image may or may not be affected by long-term immobilization, but it does not relate to the information presented in the question. The remaining options are not relevant to the described situation.