Question 1

You have medicated your patient for complaints of pain. You tell your patient you will return in 15 minutes to check on them. When you do return in the 15 minutes, what aspect of a therapeutic relationship are you reinforcing?

Accepted Answer

When you return to assess the patient's pain within the 15-minute time frame you promised, you are building trust in your relationship with that patient. Trust is the foundation of a therapeutic relationship. Keeping your promises and following through with commitments made to your patient are an important first steps in a therapeutic relationship.

Question 2

Natalia, an 18-year-old college student, is in her first trimester. She calls a nurse working at a clinic and reports increased vaginal discharge that is thin and colorless in appearance. The most appropriate INITIAL response of the nurse is:

Accepted Answer

Increased thin and colorless vaginal discharge is expected during the first trimester. In fact, Leukorrhea is expected throughout pregnancy. This type of discharge does not require immediate medical care. Tampons are not recommended during pregnancy, as increase the risk for infections. Acknowledging leukorrhea as a distressing symptom may be considered, but the statement does not address the client's main concern. Informing the client that this type of discharge is a normal occurrence facilitates re-assurance and understanding of physiological changes during pregnancy.

Question 3

Lauren, a G1P0 at 37 weeks' gestation, calls the clinic and tells the nurse that her baby has been moving a lot less for the past two days. Which of the following responses made by the nurse is the most appropriate in this situation?

Accepted Answer

The most appropriate response is: "Lie down on your side and note how long it takes for you to feel 10 distinct movements." This is the most re-assuring response. In the third trimester, it is recommended that pregnant women spend some time each day counting fetal movements. Lying on the side can help the mother concentrate. If the client does not feel ten fetal movements in two hours, she must see her physician right away. Increasing intake of foods that are high in sugar is not recommended, as pregnant women are more vulnerable to cavities. While there is a some evidence that a warm bath could stimulate fetal movement, hot baths should be avoided during pregnancy.

Question 4

A client is rushed to the emergency department due to left-sided substernal chest pain, which was unresolved by sublingual nitroglycerin. Acute myocardial infarction is suspected. The client tells the nurse, "I am scared. Am I dying?" Which of the following responses made by the nurse is the most therapeutic?

Accepted Answer

The most therapeutic response is: "Tell me how you feel right now." The response validates the client's feelings, which facilitates feeling of comfort and safety. The other responses offer false assurance. They are not appropriate and are non-therapeutic.

Question 5

A nurse meets with the family members of a client with Alzheimer's disease. The nurse and the family agree that effective communication is essential when caring for the client. The nurse encourages the family members to adhere to which of the following strategies when communicating with the client?

Accepted Answer

The family members are instructed to ask one question at a time. The family members are taught to give one-step directions. Speaking in a loud voice can agitate the client. It is recommended that the family members speak distinctly without shouting and use pauses to give the client time to process the information. Eye contact is important. Facial expression and body language add more information to the communication. If the client has difficulty understanding the first time, do not repeat; instead, rephrase.

Question 6

A nurse is assigned to care for Meizhen, an immigrant from China. The client is a traditional Chinese woman. When communicating with the client, the nurse keeps in mind that the client is more likely to demonstrate the following EXCEPT:

Accepted Answer

Eye contact may be considered inappropriate in some southeast Asian cultures. The nurse should respect the client's culture and beliefs. The nurse should also note that in some southeast Asian cultures, the word no may be interpreted as disrespectful.

Question 7

A nurse is caring for a 21-year-old female who has a phobic disorder. Which of the following is the most effective nursing intervention when caring for the client?

Accepted Answer

The most effective intervention is to encourage the client to identify the source of anxiety. Anxiety is often displaced as a phobia. Writing on a journal can be helpful, but its role in treating phobia is limited. Problem solving is more appropriate to clients with clients who are diagnosed with obsessive-compulsive disorder. Relaxation techniques are not enough to approach phobia.

Question 8

Marsha, a registered nurse, is caring for Mrs. Mitchell, who is diagnosed with post-traumatic stress disorder. Mr. Mitchell approaches the nurse in private and tells her that he does not believe that his wife has the disorder. Which of the following is the best action of Marsha?

Accepted Answer

The best action of the nurse is to provide the husband with information about post-traumatic stress disorder. Facilitating understanding about PTSD encourages the husband to participate in the client's care more readily. Problem solving does not help clarify the concern. The nurse may discuss the husband's thoughts about the diagnosis after providing information about PTSD.

Question 9

A nurse is assigned to care for a female client who practices Hinduism. The nurse is aware that the religion prohibits its members to consume certain types of foods. The nurse informs the dietician that the clientshould not be served which of the following food items?

Accepted Answer

Veal is prohibited to members of Hinduism. Beef is also not allowed. Many practicing Hindus are vegetarians. Islam and Judaism prohibit pork. The Church of Jesus Christ of Latter-Day Saints prohibits alcohol, coffee, and tea.

Question 10

A nurse is caring for Maxine, a 21-year-old female with mania. Which of the following communication techniques is the most effective when talking to a manic client?

Accepted Answer

The nurse should focus and redirect conversation if necessary. Clients with mania have elevated and expansive moods and racing thoughts. The client should not be allowed to talk about different topics or asked open-ended questions. These communication techniques may cause the client to feel out of control. The nurse must be in control of the conversation or situation. He or she must be firm when talking to the client.

Question 11

A male Orthodox Jew is admitted to the unit for a scheduled surgery. The nurse notes that the client adheres to kosher dietary laws. Which of the following food items is not appropriately offered to the client?

Accepted Answer

Milkshake and goat meatare not offered to an Orthodox Jew. Kosher law prohibits any combination of meat and milk in one meal. Fish that have scales and fins and kosher certified meats of cloven-hoofed animals are allowed.

Question 12

Bessie, a practicing Jehovah's Witness, has been told that a surgery is needed. The nurse caring for the client is aware of the client's religious preferences. Based on Bessie's religion, the nurse appropriately documents which of the following?

Accepted Answer

Bessie, a practicing Jehovah's Witness, cannot receive blood and blood products. Surgery and synthetic drugs are not prohibited to its members, but drugs containing blood are not acceptable. Members of this religion are prohibited from organ donation.

Question 13

Betty, a 52-year-old female who divorced her husband a year ago, is brought to the hospital. The client's adult daughter reports that her mother has refused to get out of bed, eat, or bathe for three days. Betty is diagnosed with major depression on admission. Which of the following questions asked by the admitting nurse is the most appropriate?

Accepted Answer

The most appropriate question to ask a client with major depression during the first meeting is: "How do you feel about your life after the divorce?" The nurse must first determine the client's perceived thoughts, feelings, and problems. The other items are not therapeutic. Why questions place the client in a defensive position. Asking the client for solutions to problems, such as in B, is not within the scope of nursing. Clients with major depression find it difficult to focus and identify problems, so D is not therapeutic.

Question 14

Thomas, a 35-year-old stay-at-home dad, is diagnosed with major depression. On assessment, the nurse notes new cutting marks and old scars on his arms and wrists. The nurse suspects that Thomas is suicidal. Which of the following strategies is most appropriate to use with Thomas?

Accepted Answer

The most appropriate strategy is to directly ask the client about suicidal thoughts with care. The client should be assessed directly, not through a family member. Assessment must be done before evaluating whether suicide precautions are necessary. D does not directly address the suspicion.

Question 15

White, a 55-year-old sales agent, has been drinking 7 to 10 cans of beer per day for the past five years. The client says alcohol helps him function at work. Mr. White says, "I'm sure I can cut down on my drinking. Drinking socially won't be a problem." Which of the following responses made by the nurse is the most appropriate?

Accepted Answer

The question, "Has alcohol caused any major problems in your life?" is the most appropriate response. Asking this question will help the client recall the destructive results of alcohol abuse and the reasons behind the abuse. Asking the client how many cans of beer a social drinker consumes on a daily basis and what he can do to become a social drinker encourage the client to defend himself and to deny the existence of the problem. Asking why questions places the client in a defensive position.

Question 16

A father brings his seven-month-old baby boy to a well-baby clinic for a routine examination. During the assessment, which of the following questions should the nurse ask the father to obtain the most important information about the child's growth and development?

Accepted Answer

"Can he sit up unsupported?" A seven-month-old child is expected to sit unsupported. Transferring an object from one hand to another and making babbling or cooing sounds are expected in younger infants, usually around five months. Cruising along the furniture is expected in infants between 10 and 12 months.

Question 17

Emily is a 75-year-old female who is diagnosed with a terminal disease. One afternoon, the client says, "If I can only live to see my granddaughter born, I would be OK." The nurse recognizes that the client demonstrates:

Accepted Answer

The elderly client demonstrates bargaining. Bargaining is manifested by if this, then that statements. Disbelief is manifested by no, not me responses. In depression, the client accepts the inevitable, but he or she can still be exceedingly sad about the condition. Acceptance occurs when the client is at peace with the terminal disease.

Question 18

A 25-year-old female was admitted to a facility for the treatment of substance abuse. The admission was ordered by the court after the client attempted to harm her daughter and planned a (second) suicide attempt. A central part of the treatment program is to complete a series of group meetings. On the fifth day of the treatment, the client tells the nurse, "You cannot make me go to this group thing today. I am not going. I am getting out of here." Which of the following is the most appropriate response made by the nurse?

Accepted Answer

The correct answer is: "You are required to stay in the facility; however, you have the right to informed consent in regard to group treatment participation."Although the client was involuntarily admitted to the facility, she has the right to informed choice. A mentally ill client has the right to accept treatment or refuse treatment. She also has the right to privacy, and confidentiality.

Question 19

Brad, a male client, was admitted to the nursing unit. During the admission, he was diagnosed with human immunodeficiency virus or HIV. A physician has just ordered the client for discharge. The nurse emphasizes which of the following home instructions to the client as the topmost priority at this stage of the disease?

Accepted Answer

The nurse should emphasize the importance of practicing safe sex. Preventing the spread of the virus is the topmost priority at this stage of the disease. The nurse must ensure that the newlydiagnosed HIV client is wellinformed about how the disease is transmitted and how it is prevented. Compliance with prescribed medications is important, but the nurse must first ensure that the client knows how to prevent HIV transmission. Nutritional recommendations and limitations are not significant at this stage. Physician visits are important, but practicing safe sex is the most important teaching for the client.

Question 20

Mary Lou is an 85-year-old female client who is brought to the emergency department due to a fractured clavicle. On physical assessment, the nurse notes bruises in varying coloration on the upper arms, thorax, and upper legs. The client informs the nurse that her daughter hits her every time she fails to quiet down her granddaughter. Which of the following is the most appropriate response of the nurse?

Accepted Answer

The correct response is: "Violence at home is a legal issue. I have to report this, but I am assuring you that the information will be kept confidential." The client should be assured that the nurse will keep the information confidential, unless the nurse is under a legal obligation to share the information. Options A, B, and D do not address the legal consequences of the situation. Although assuring the client that she is safe is encouraged, the nurse should avoid asking why questions. Questions that start with why puts the client in a defensive stance.

Quiz 2: Partnership