A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells
the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?
Ineffective coping related to denial
Emotional conflict due to stress
Deficient knowledge of MI lifestyle changes
Anxiety related to treatment plan
The Correct Answer is A
Choice A reason: This is the correct answer because ineffective coping related to denial is a likely problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Denial is a defense mechanism that helps people avoid facing unpleasant or threatening realities, such as having a heart attack and needing hospitalization and treatment. The nurse should assess the client's coping skills and provide emotional support and education.
Choice B reason: Emotional conflict due to stress is not a specific problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Emotional conflict is a state of having mixed or contradictory feelings about something or someone, such as family, work, or self. Stress is a response to any physical, psychological, or environmental demand that exceeds one's coping resources. The nurse should assess the client's sources of stress and conflict and help him manage them.
Choice C reason: Deficient knowledge of MI lifestyle changes is not a primary problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Deficient knowledge is a state of lacking information or understanding about something, such as disease process, treatment options, or self-care measures. Lifestyle changes are modifications in one's habits or behaviors that promote health and well-being, such as diet, exercise, smoking cessation, or stress management. The nurse should assess the client's learning needs and readiness and provide appropriate education.
Choice D reason: Anxiety related to treatment plan is not an evident problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Anxiety is a feeling of apprehension, worry, or fear that interferes with one's normal functioning or well-being. Treatment plan is a set of goals, interventions, and outcomes that guide the care of a client with a specific health problem, such as MI. The nurse should assess the client's level of anxiety and provide information and reassurance about his treatment plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B reason: the client with antisocial behavior is at risk of being harmed by other clients or harming others. The nurse should intervene immediately to prevent violence and ensure safety.
Choice A reason: the client with anorexia nervosa who is refusing to eat the evening snack is not in immediate danger. The nurse should monitor the client's nutritional status and weight, but this can be done later.
Choice C reason: the client with bipolar disorder who is pacing around the lobby is not in immediate danger. The nurse should assess the client's mood and energy level, but this can be done later.
Choice D reason: the client with major depression who refuses to participate in group is not in immediate danger. The nurse should encourage the client to join the group, but this can be done later.
Correct Answer is B
Explanation
Choice A reason: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B reason: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C reason: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D reason: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
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