1. A client who has been "I hear what you are saying, but I don't share your
hospitalized with a para- belief." Paranoid beliefs are coping mechanisms
noid disorder refuses to used by the client & therefore are not easily re-
turn off the lights in the linquished. It's important not to support the belief
room at night and states, & not to ridicule, argue, or criticize it.
"My roommate will steal
me blind." Which is the ap-
propriate response by the
nurse?
2. A client who has just "You seem very distressed over learning you
received a diagnosis of have asthma." Clients who have learned that
asthma says to the nurse, they have a chronic illness may exhibit denial,
"This condition is just an- anger, or sarcasm because of fear associated
other nail in my coffin." with the chronic illness. It is important for the
Which response by the nurse to convey an accepting attitude to enhance
nurse is therapeutic? mutual respect and trust.
3. The client is a Jehovah's Support the client's decision not to receive a
Witness and refuses to blood transfusion. A client's cultural and ethnic
have a blood transfusion. background influences the response to health,
The nurse should take illness, surgery, and death. Awareness of cultural
which most appropriate differences enhances the nurse's knowledge of
action? how a health care experience may be perceived
by the client or family. In the Jehovah's Witness
religion, the administration of blood and blood
products is forbidden; therefore the nurse would
support the client's decision. Trying to convince
the client of the need for the blood transfusion
is inappropriate and does not respect the client's
cultural beliefs.
4. The mother of 6-year-old "What do you and your husband believe is the
twins says to the nurse, right thing for your children?" The most therapeu-
"My mother-in-law doesn't tic response is the one that encourages open ex-
think our children should pression of feelings and empowers the grieving
come to the funeral ser- relative.
vice for their grandfather.
What do you advise?" The
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, Psych Exam Test Questions with 100% Verified Answers Graded A+
nurse most appropriate-
ly responds by making
which statement?
5. A 63-year-old woman "It's OK to grieve and be angry with your daugh-
whose husband died 2 ter and anyone else for a time." The therapeutic
months ago says to the statement is the one that gives the client permis-
visiting nurse, "My daugh- sion to grieve and acknowledges that anger is
ter came over yesterday part of loss and that it may be aimed at the peo-
to help me move my hus- ple who are trying most to help and are closest.
band's things out of our
bedroom, and I was so an-
gry with her for moving
his slippers from where he
always kept them under
his side of our bed. She
doesn't know how much
I'm hurting." Which state-
ment by the nurse would
be therapeutic?
6. After a tonsillectomy, Prone or side-lying position after tonsillectomy to
a child is brought to facilitate drainage.
the pediatric unit. The
nurse should appropriate-
ly place the child in which
position?
7. A nurse is monitoring a Nausea is an early sign of increased ICP. Late
7-year-old child who sus- signs include a significant decrease in level of
tained a head injury in a consciousness, Cushing's triad (increased sys-
motor vehicle crash for tolic blood pressure and widened pulse pres-
signs of increased in- sure, bradycardia, and irregular respirations),
tracranial pressure (ICP). and fixed and dilated pupils. Other late signs
The nurse should assess include decreased motor response to command,
the child frequently for decreased sensory response to painful stimuli,
which early sign of in- posturing, Cheyne-Stokes respirations, and pa-
creased ICP? pilledema.
8.
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