Hesi Quiz: Foundations and Modes of Care; Nursing Care of the Newborn; Pregnancy, Labor, childbirth, Postpartum - At Risk
During a group therapy session some members accuse another client of intellectualizing to avoid discussing feelings. The client asks whether the nurse agrees with the others. What is the best response by the nurse? 1 "It seems that way to me, too." 2 "What's your perception of my behavior?" 3 "Are you uncomfortable with what you were told?" 4 "I'd rather not give my personal opinion at this time."
"Are you uncomfortable with what you were told?" Asking the confronted client whether he or she is uncomfortable with what he or she is being told will help the client identify behaviors and feelings in a nonthreatening manner. Agreeing with the confronting group members indicates a lack of acceptance of the client. The nurse's behavior is not the issue; the situation should be turned back to the client's behavior. Evasion and refusal to answer will have the psychological effect of removing the nurse from the group.
A client in the thirty-eighth week of gestation exhibits a slight increase in blood pressure. The primary healthcare provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? 1 "It increases blood flow to the fetus." 2 "It decreases intra-abdominal pressure." 3 "It increases the mean arterial pressure." 4 "It prevents the development of thrombosis."
"It increases blood flow to the fetus." The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bed rest the blood pressure decreases. The side-lying position does not prevent thrombosis; bed rest and immobility may increase the risk of thrombosis.
A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence
Autonomy Autonomy is the ethical principle of respecting the independence and right to self-determination of others. In this situation the nurse focuses on helping the client make a choice. Justice is the ethical principle that requires all people to be treated fairly, regardless of sex, age, religion, diagnosis, marital status, or socioeconomic level. Veracity is the ethical principle that requires truthfulness. Beneficence is the duty to do good and promote the welfare of others.
In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. What is this technique known as? 1 Empathy 2 Sympathy 3 Projection 4 Acceptance
Empathy Empathy is the projection of self into another's emotions to share the emotions and the other's state of mind; this technique helps the nurse understand the meaning and significance of the experience to the client. Sympathy is a shared expression of sorrow over a real or imagined loss. Projection is an unconscious defense mechanism, not a therapeutic technique. Acceptance does not require the nurse to project the self into the client's emotions; rather, it involves accepting the client and the emotions.
A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do? 1 Honor the client's decision and document the behavior and all interventions. 2 Use an authoritarian approach to induce the client to take the prescribed medication. 3 Call the primary healthcare provider and request that the client be discharged against medical advice. 4 Start proceedings to have the client declared incompetent and seek a court order permitting medication.
Honor the client's decision and document the behavior and all interventions. A client has the right to refuse treatment and should not be forcibly medicated unless the client is deemed dangerous to self or others. An authoritarian approach is not therapeutic and may compromise the nurse-client relationship. Calling the primary healthcare provider is premature; first the nurse should attempt therapeutic interventions to meet the client's needs. Starting proceedings to have the client declared incompetent is appropriate for a client who is considered to be dangerous to self or others or incompetent to evaluate necessary treatment.
In specific situations gloves are used to handle newborns whether or not they are positive for human immunodeficiency virus (HIV). When is it unnecessary for the nurse to wear gloves while caring for a newborn? 1 Offering a feeding 2 Changing the diaper 3 Giving an admission bath 4 Suctioning the nasopharynx
Offering a feeding Standard precautions do not include the use of gloves for feeding. Wearing clean gloves for diaper changes of newborns is standard protocol. Clean gloves should be worn for all admission baths, because the nurse will be exposed to blood and amniotic fluid. Clean gloves should also be worn while the nurse suctions an infant.
The wife of a client who is dying tells the nurse that although she wants to visit her husband daily, she can visit only twice a week because she works and has to take care of the house and their cat and dog. What defense mechanism does the nurse conclude that the client's wife is using? 1 Projection 2 Sublimation 3 Compensation 4 Rationalization
Rationalization Rationalization is offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. Projection is the denial of emotionally unacceptable feelings and the attribution of the traits to another person. Sublimation is the substitution of a socially acceptable behavior for an unacceptable feeling or drive. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.
A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor? 1 Scheduling pain medication at regular intervals 2 Administering the medication only when the pain is severe 3 Avoiding the administration of medication unless it is requested 4 Recognizing that less pain medication will be needed by this client compared with other women in labor
Scheduling pain medication at regular intervals This client will have a lower tolerance for pain and a greater need for pain relief. Larger doses may be needed if pain medication is administered only when the pain is severe. Delays increase anxiety and discomfort, and larger doses will be necessary. Individuals who abuse drugs require more medication than do others because of tolerance to the addictive drug.
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother is by performing a heel stick blood test on the newborn. What specifically does this test determine? 1 Blood acidity 2 Glucose tolerance 3 Serum glucose level 4 Glycosylated hemoglobin level
Serum glucose level Obtaining a blood glucose level is a simple, cost-effective method of testing newborns for suspected hypoglycemia. Although the acidity of the blood will indicate whether the newborn has metabolic acidosis as a result of hypoglycemia, it is more important to determine whether the newborn has hypoglycemia so it can be corrected before acidosis develops. The glucose tolerance test and glycosylated hemoglobin level test are not used in newborns.
A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis? 1 Making huge efforts to avoid "any kind of bug or spider" 2 Experiencing flashbacks to an event that involved a sexual attack 3 Spending hours each day worrying about something "bad happening" 4 Becoming suddenly tachycardic and diaphoretic for no apparent reason
Spending hours each day worrying about something "bad happening" Using worrying as a coping mechanism is a behavior characteristic of GAD. Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic attack. Avoiding bugs and spiders would indicate a phobia. Flashbacks to traumatic events are characteristic of posttraumatic stress disorder (PTSD).
A nurse is aware that a coworker's mother died 16 months ago. The coworker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior? 1 It is an expected response. 2 Most people cry when their mother dies. 3 The coworker may need help with grieving. 4 The coworker was extremely attached to the mother.
The coworker may need help with grieving. Crying is a release, but the individual should have developed effective coping mechanisms by this time. The coworker may need help with the grieving process. Excessive crying 16 months after the death of a loved one is not an expected response. People express grief in a variety of ways, not necessarily by crying. Concluding that the coworker was extremely attached to the mother is an assumption and is not a valid conclusion.
