1. Answer A. The nature of the accident, the child’s pain, and the unfamiliar facility environment support a nursing diagnosis of Anxiety. A diagnosis of Hypothermia related to head injury isn’t appropriate because the child is alert and oriented, indicating that a head injury, if present, isn’t severe and is unlikely to cause hypothermia. Unlike the homecoming of a new baby or riding a bicycle for the first time, a car accident isn’t a maturational crisis.
2. Answer C. This response conveys empathy and invites further discussion of the client’s concerns. The other options block communication by failing to address the client’s concerns and feelings.
3. Answer B. The adolescent may be introjecting (assuming as her own) her parents’ belief that anger shouldn’t be outwardly expressed. She may also be holding and somatizing in her angry feelings, as evidenced by her increased blood pressure. (A blood pressure rise is a common physiological reaction to the fight-or-flight response that may be brought on by strong emotions. Habitual failure to express anger may contribute to hypertension
4. Answer A. Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don’t show interest in solitary activities. They also pursue relationships in order to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren’t met, this isn’t a typical response.
5. Answer A. Breast milk is the ideal food for a newborn. As a result, the infant will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother’s breast-feeding attempts are unsatisfactory. Nurses shouldn’t suggest giving formula to a breast-feeding infant.
6. Answer C. Open-ended questions allow the teen to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though he’s being probed with unnecessary questions. Writing everything down during the interview can be a distraction and won’t allow the nurse to observe how the adolescent behaves. Discussing the nurse’s thoughts and feelings may bias the assessment and is inappropriate when interviewing any client.
7. Answer B. Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Option A is the best answer.
8. Answer C. Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn’t need professional help. Discussing the concerns with the client’s husband doesn’t address the client’s needs. In fact, the client may feel that the nurse violated confidentiality.
9. Answer A. If a client feels overwhelmed by the additional tasks brought on by her new role as a mother, the nurse should help her break down large tasks into smaller, more manageable ones. Encouraging her to work faster or reassuring her that her feelings will soon pass wouldn’t address her needs. The nurse can’t help the client accept her new role if the client feels overwhelmed.
10. Answer B. The client and her husband are working together for a common goal. He’s offering support, and they’re sharing the experience of childbirth, making Readiness for enhanced family coping related to participation in pregnancy and delivery an appropriate nursing diagnosis. The other options suggest that the couple have a problem that isn’t indicated in the question.
11. Answer C. It’s essential that clients with AIDS follow safer-sex practices to prevent transmission of the human immunodeficiency virus (HIV). Although it’s helpful if clients with AIDS avoid using recreational drugs and alcohol, it’s more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.
12. Answer D. The stress of being in an unfamiliar situation, such as admission to a hospital, can cause confusion in geriatric clients. Depression doesn’t produce confusion, but it can cause mood changes, weight loss, anorexia, constipation, and early morning awakening. In geriatric clients, long-term memory usually remains intact, although short-term memory may be altered. Decreased LOC doesn’t normally result from aging; therefore, it’s a less likely cause of confusion in this client.
13. Answer C. Spiritual distress related to experienced loss most accurately describes the problem; therefore, nursing care should be based on this diagnosis. Families may not have altered family process or suffer from ineffective coping. Although the family may feel powerless, this isn’t the most accurate diagnosis.
14. Answer C. Abstract thinking is the ability to conceptualize and interpret meaning. It’s a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can’t conceptualize and comprehend abstract meaning. They interpret such statements as "Don’t cry over spilled milk" in a literal sense such as "Even if you spill your milk, you shouldn’t cry about it."
15. Answer C. Providing privacy for the conversation is a form of active listening, which focuses solely on the client’s needs. Asking why the client is concerned, changing the subject, or giving advice tends to block therapeutic communication.
16. Answer A. Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn’t focus on counseling regarding health care costs. Most clients referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.
17. Answer C. Repression, the unconscious exclusion of painful or conflicting thoughts, impulses, or memories from awareness, is the primary ego defense. Other defense mechanisms tend to reinforce anxiety. Introjection is an intense identification in which one incorporates another person’s or group’s values or qualities into one’s own ego structure. Regression is a retreat to an earlier level of developmental behavioral during a time of stress. Denial is the avoidance of unpleasant realities by ignoring them.
18. Answer B. When talking with adolescents, it’s best to get their viewpoints and thoughts first. Doing so promotes therapeutic communication. Asking whether the mother knows or about the baby’s father focuses the attention away from the adolescent. Making a statement about her being too young to be pregnant is a value judgment and inappropriate.
19. Answer A. During chemotherapy, playing cards is an appropriate diversional activity because it doesn’t require a great deal of energy. To conserve energy, the client should avoid such activities as taking long trips, bowling, and eating in restaurants every day. However, the client may take occasional short trips and can dine out on special occasions.
20. Answer A. With an obsessive-compulsive client, a goal of treatment is to throw away hoarded items. Moving the hoarded items or rearranging them wouldn’t indicate progress because these actions allow the inappropriate behavior to continue.
21. Answer D. By age 9 or 10, most children have an adult concept of death. Caregivers should discuss death with them in terms consistent with their developmental stage. School-age children respond well to concrete explanations about death and dying. Preschoolers, not school-age children, typically view death as temporary and reversible. School-age children may fantasize about the unknown aspects of death; these fantasies may increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety.
22. Answer C. The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who’s chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children.
23. Answer D. This statement demonstrates a realistic understanding of the client’s disorder and effective family coping with the challenges it presents. Options A and B indicate that the family is having difficulty adjusting. Option C suggests that the family is in denial or has an unrealistic view of the prognosis for a client with Alzheimer’s disease.
24. Answer B. Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.
25. Answer D. The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.