Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

"I can learn to manage my thoughts better through therapy."

"This diagnosis means that I am crazy."

"Many people have the same response to a stressful situation as I am having right now."

"I can use holistic approaches like meditation to help my symptoms."

"I will probably need to be on medication for the rest of my life."

"I am at high risk for post-traumatic stress disorder because I have acute stress disorder."

Answer and Explanation

Correct Answer : B,E,F

B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.

Client Statement: D. The client is frightened that the hospital will burn down.

This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.

A. Take prescribed cortisone accurately.<br> B. Increase daily intake of sodium in diet. C. Avoid extreme environmental temperatures. D. Use a walker when weakness occurs

Correct Answer is C

Explanation

Rationale

A. It's crucial for the client to adhere strictly to the prescribed dosage and schedule to maximize therapeutic benefits and minimize potential side effects. However, temperature regulation is priority

B. Celiac disease requires strict adherence to a gluten-free diet to prevent intestinal damage, while multiple sclerosis management may involve dietary strategies to manage symptoms like fatigue or bladder dysfunction. However, increasing sodium intake generally is not a primary concern unless there are specific indications related to multiple sclerosis symptoms or medication effects.

C. Temperature sensitivity is common in multiple sclerosis, and exposure to extreme heat or cold can exacerbate symptoms such as fatigue, weakness, and cognitive dysfunction. Managing environmental temperature exposure is crucial to minimizing symptom exacerbation and maintaining comfort and safety.

D. Mobility aids, such as walkers, can assist individuals with multiple sclerosis during periods of weakness or impaired balance. Using a walker appropriately can help prevent falls and promote safe mobility. However, this instruction may be more specific to managing symptoms of multiple sclerosis rather than addressing the complex dietary needs associated with celiac disease.

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Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Client Statement: D. The client is frightened that the hospital will burn down.

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Correct Answer is C

Explanation

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.