(N129/2) Practice

A young client who has become a mother for the first time is showing signs of being anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect? 1. Primary prevention 2. Tertiary prevention 3. Secondary prevention 4. Therapeutic prevention

1 Rationale: Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example? 1. Dissociation 2. Transference 3. Displacement 4. Identification

1 Rationale: Speaking in the third person reflects poor ego boundaries and dissociation from the real self. Transference is the movement of emotional energy and feelings that one has for one person to another person. Displacement is an attempt to reduce anxiety by transferring the emotions associated with one object or person to another. Identification is an attempt to increase self-esteem by acquiring the attributes or characteristics of an admired individual.

After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty? 1. Personal identity 2. Social interaction 3. Sensory perception 4. Verbal communication

2 Rationale: Characteristics of clients with problems with social interaction include avoidance of others, problematic patterns of interaction, and an inability to establish or maintain stable supportive relationships. Withdrawal from others is not a characteristic of individuals with difficulties involving personal identity. These clients usually exhibit an inability to distinguish between the self and nonself. Withdrawal from others is not a characteristic associated with clients who have alterations in sensory perception. A client with impaired sensory perception demonstrates altered processing of sensory stimuli and an exaggerated or distorted response to stimuli. Withdrawal from others is not a characteristic of clients who have difficulty communicating with others. A client who has problems communicating has a decreased ability to receive, process, or transmit communication.

A child has been found to have acute myelogenous leukemia. The practitioner has discussed the diagnosis and prognosis with the parents. Later, after visiting their child, the parents have a bitter argument. The nurse identifies what defense mechanism? 1. Denial 2. Projection 3. Displacement 4. Compensation

3 Rationale: The parents are focusing their feelings about their child's prognosis on someone or something else—in this case, each other. Denial is ignoring, avoiding, or refusing to recognize painful realities. Projection is the attribution of one's own feelings to another person. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

After speaking with the parents of a child dying of leukemia, the primary healthcare provider gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do? 1. Follow the order as given by the primary healthcare provider. 2. Refuse to follow the primary healthcare provider's order unless the nursing supervisor approves it. 3. Ask the primary healthcare provider to write the order in pencil on the child's chart before leaving the room. 4. Determine whether the family is in accord with the primary healthcare provider while following hospital policy.

4 Rationale: Determining whether the family is in accord with the primary healthcare provider while following hospital policy verifies family and provider agreement and uses institutional policy developed by the ethics committee. Neither the nurse nor the nursing supervisor should accept this inappropriate order. The order must be present in ink on the written record.

A client on the psychiatric service is pacing around the unit at a moderate rate and looking to either side of the hall. What is the most appropriate intervention by the nurse? 1. Talking with the client to assess the meaning of the behavior 2. Warning the client that if the pacing does not stop a privilege will be removed 3. Approaching the client and recommending the performance of relaxation exercises 4. Allowing the client to continue pacing the hall and watching carefully from a distance

1 Rationale: The nurse's observations need to be validated with the client. Warning the client that if the pacing does not stop a privilege will be removed is punitive and threatening. The client's behavior indicates a moderately high level of anxiety; relaxation techniques will probably be unsuccessful at this time. Allowing the client to continue pacing the hall and watching carefully from a distance may be unsafe. Pacing indicates rising anxiety and agitation; early intervention is essential.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? 1. "You shouldn't give up hope." 2. "Being incapacitated is difficult for you." 3. "Would you like to speak to a religious advisor?" 4. "Have you talked to your family about your feelings?"

2 Rationale: The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings. The response "You shouldn't give up hope" rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to someone else. The response "Have you talked to your family about your feelings?" changes the focus from the client's feelings to the family's role.

The practitioner prescribes a tricyclic antidepressant medication to ease a suicidal client's depression. What factor should the nurse consider when initiating treatment with this type of medication? 1. Eating aged cheese may cause a hypertensive crisis. 2. There may not be a noticeable improvement for 2 to 3 weeks. 3. They must be given with milk to avoid gastrointestinal irritation. 4. Blood specimens are required weekly for 3 months to check for a therapeutic drug level.

2 Rationale: These drugs do not produce an immediate effect; nursing measures must continue to decrease the risk of suicide. Avoiding aged cheese is a precaution taken with monoamine oxidase (MAO) inhibitors. Giving the medicine with milk is unnecessary. Blood specimens are not necessary; toxicity is not as prevalent a problem with tricyclic antidepressants as it is with medications such as lithium.

An extremely anxious client enters a crisis center and asks a nurse for help. Which initial response best reflects the nurse's role in crisis intervention? 1. "Tell me what you've done to help yourself." 2. "I'll be here for you to help you figure things out." 3. "I understand that in the past you've had problems." 4. "Tell me about the things that are bothering you the most."

2' Rationale: Clients in crisis need assistance with coping; the nurse must be involved with problem solving. Clients in crisis initially need to trust the nurse. Telling the client that they are there to help develops trust. Asking what the client has done to help himself, stating the client has had problems in the past, and asking the client to discuss what is most bothering them all do not focus on the nurse's involvement with problem solving.

A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1. Undoing 2. Projection 3. Suppression 4. Intellectualization

3 Rationale: Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.

A nurse is assisting with an electroconvulsive therapy (ECT) treatment. The healthcare provider administers the electrical shock, and a seizure of 60 seconds' duration results. Place in priority order the nursing actions that should be taken after the seizure ends. 1. Checking vital signs 2. Orienting the client to place and time 3. Ensuring an open airway 4. Assessing the client for the presence of short-term memory loss 5. Providing nourishment because the client has been on nothing-by-mouth (NPO) status

3, 1, 2, 4, 5 Rationale: During the seizure the client is not breathing or swallowing, and mucous secretions collect in the oral cavity, so ensuring a patent airway is a priority. ECT and the anesthesia used during the treatment can cause significant temporary physiologic changes. Checking the client's vital signs is necessary to identify and address any complications quickly. Orienting the client to place and time as the anesthesia wears off will ease the client's anxiety. As the client becomes more alert, memory questions can be asked to determine the level of short-term memory loss. This is a common side effect of ECT, and its presence or absence should be documented. Finally, when the client is completely awake and oriented and the vital signs are stable, nutritional needs may be addressed.

A client comes to the crisis center because her spouse has stated that he wants a divorce. The client states that she is angry and feels rejected. What should the nurse encourage the client to do to cope with this emotional trauma? 1. Use other defense mechanisms. 2. Avoid talking with her spouse. 3. Date new people whenever possible. 4. Learn to constructively vent her anger.

4 Rationale: Coping mechanisms, such as venting anger, may help the client address the feelings of rejection. Defense mechanisms are usually subconscious and not under a person's control; specific coping approaches should be explored. Avoidance is a defense mechanism that may reduce anxiety, but it will not assist in problem-solving. Dating should not be encouraged until the client has worked through the current crisis.