Extract:

Question 1 of 5

The nurse is caring for a client who says, 'I don't want to talk with you because you're only the nurse. I'll wait for my doctor.' Which statement should the nurse say in response to the client?

Correct Answer: B

Rationale: The nurse uses techniques of therapeutic communication to reflect the client's statement (option 2), redirect feelings back to the client for validation, and focus on the client's desire to talk with the doctor. Options 1 and 3 are nontherapeutic responses and are defensive responses. Option 4 reinforces the client's behavior and does not encourage client expression of feelings.

Question 2 of 5

During an office visit, a prenatal client diagnosed with mitral stenosis states being under a lot of stress lately. During the examination, the client questions the nurse about the assessment and behaves anxiously. Which is the appropriate nursing action at this time?

A. Tell the client not to worry. B. Refer the client to a counselor. C. Assume that the client's anxiety will lessen when the assessment is finished. D. Explain the purpose of the nurse's actions and answer the client's questions.

Correct Answer: D

Rationale: In the prenatal cardiac client, stress should be reduced as much as possible. The client should be provided with honest and informed answers to questions to help alleviate unnecessary fears and emotional stress. Explaining the purpose of nursing actions will assist with decreasing the stress level of the client. The remaining options are nontherapeutic because they neglect to deal with the client's concerns.

Question 3 of 5

The nurse evaluates the client response to a 2-week trial of electroconvulsive therapy (ECT). Which data indicates to the nurse that treatment is successful?

A. The client no longer experiences phobias and anxiety. B. The client no longer counts objects out loud. C. The client is no longer mute and withdrawn. D. The client no longer displays overreaction to events.

Correct Answer: C

Rationale: ECT is primarily used for severe depression or catatonia. A client no longer being mute and withdrawn indicates improved engagement and mood, suggesting successful treatment. Other options are less directly associated with ECT outcomes.

Question 4 of 5

A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother with making the decision?

A. Discuss the procedure with the male members of your family.' B. Circumcision is a difficult decision, but your primary health care provider is the best, and it's better to get it done now than later.' C. You know they say it prevents cancer and sexually transmitted infections, so I would definitely have my son circumcised.' D. Circumcision is a difficult decision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it.'

Correct Answer: D

Rationale: Informed decision making is the strategic point when answering this question. The nurse should provide educational materials and answer questions pertaining to the education of the mother. Providing written information to the mother will give her the information she needs to make an educated and informed decision. The nurse's personal thoughts and feelings should not be part of the educational process. The remaining options are not well focused on answering the mother's concerns.

Question 5 of 5

The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.

A. administers medications as ordered B. uses gentle touch to reassure the client C. tells the client that others see or hear what he does D. distracts the client by placing him in the dayroom with others E. asks the client if he hears voices telling him to harm himself or others

Correct Answer: A,E

Rationale: Administering medications (
A) helps manage hallucinations, and asking about harmful voices (E) assesses safety.
Touch (
B) may be misinterpreted, validating hallucinations (
C) is harmful, and distraction in a dayroom (
D) may overwhelm the client.