Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture?
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Solution
The client will maintain safety.
Option B: Maintaining safety is the priority goal for an acutely confused client who recently had surgery. All measures to promote physiologic safety and psychosocial wellbeing would be implemented.
Option A: This client would not be able of completing activities of daily living, and safety is a priority over these tasks.
Options C and D: The goals of remaining oriented and understanding communication would be appropriate only after the client’s acute confusion has resolved.
The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is:
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Solution
“I only need access to your arm. Putting up your sleeve is fine.”
Option D: The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way.
Options A and B: These responses are not therapeutic because they are challenging and rejecting.
Option C: Threatening the client is not therapeutic.
Which is the best indicator of success in the long-term management of the client?
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Solution
He learns to verbalize his feelings and concerns
Option C: The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors.
Option A: The client is encouraged to acknowledge feelings rather than being indifferent to her feelings.
Option B: Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success.
Option D: Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational.
Which of the following behaviors by a client with dependent personality disorder shows the client has made progress toward the goal of increasing problem-solving skills?
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Solution
The client asks questions.
Option B: The client with a dependent personality disorder is passive and tries to please others. By asking questions, the client is beginning to gather information, the first step of decision making.
A person with antisocial personality disorder has toughness relating to others because of never having learned to:
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Solution
Empathize with others.
Option B: The lack of superego control allows the ego and the id to control the behavior. Self-motivation and self-satisfaction are of paramount concern.
Which nursing statement is a good example of the therapeutic communication technique of focusing?
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Solution
“You mentioned your relationship with your father. Let’s discuss that further.”
Option D: This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.
A clinical instructor is correcting a nursing student’s worksheet. Which instructor statement is the best example of effective feedback?
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Solution
“Surely you didn’t do this deliberately, but you breached confidentiality by using the client’s name.”
Option C: The instructor’s statement, “Surely you didn’t do this deliberately, but you breached confidentiality by using the client’s name.” is an example of effective feedback. Feedback is a method of communication to help others consider a modification of behavior. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice or criticize the individual.
Upon evaluation of the patient’s record, the nurse sees the admission was voluntary. Based on this data, the nurse expects which patient behavior?
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Solution
A willingness to participate in the planning of the care and treatment plan.
Option D: In general, patients seek voluntary admission. If a patient seeks voluntary admission, the most likely expectation is the patient will participate in the treatment program since they are actively seeking help.
Options A, B, and C: The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a patient’s understanding of their illness, only of their desire for help.
When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following?
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Solution
The client must take benztropine (Cogentin) as prescribed to prevent a return of symptoms.
Option D: An oral anticholinergic agent such as benztropine (Cogentin) is commonly prescribed to control and prevent the return of symptoms.
Option A: Dystonic reactions are typically acute and reversible.
Option B: Dystonic reactions can be life-threatening when airway patency is compromised.
Option C: Lecturing the client about buying drugs on the street isn’t appropriate.
Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse’s interpersonal communication with the client and specific nursing interventions must be:
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Solution
flexible enough for the nurse to adjust the plan of care as the situation warrants.
Option D: A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants.
Option A: The nurse’s role should be clear; however, the boundaries or limits of this role should be flexible enough to meet client needs.
Option B: Because a client with schizophrenia fears closeness and affection, a warm approach may be too threatening.
Option C: Expressing empathy is important, but centering interventions on clearly defined limits is impossible because the client’s situation may change without warning.