possible qs Flashcards
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from post-traumatic stress disorder (PTSD) if the client makes which of the following statements?
D. “In my dreams, all I can see are the wounded reaching out and trying to grab me.”
Rationale: Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. This client’s statement about haunting dreams is typical of a client who has PTSD.
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
D. “I can review the assignments and arrange for a female nurse to care for you.”
Rationale: In this therapeutic response, the nurse demonstrates empathy by endeavoring to meet the client’s request for a female caregiver.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
A. Leaves the child’s room exactly as it was before the loss
Rationale: Grieving becomes dysfunctional when the client is unable to resume regular activities of daily living or experience emotions other than sadness or depression. An example of dysfunctional grieving is making the loved one’s room a shrine for more than a year.
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client’s disruptive behaviors. Which of the following initial actions should the nurse take?
A. Talk to the client and identify the specific limits that are required of the client’s behavior.
B. Discuss the problem in a community meeting with the other clients on the unit present.
C. Escort the client to her room each time the nurse observes the client socializing with other clients.
D. Tell the other clients to ignore the client’s lies.
A. Talk to the client and identify the specific limits that are required of the client’s behavior.
Rationale: Discussing the problem behaviors with the client and informing her of which behaviors cannot be done on the unit is therapeutic communication.
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing?
A. Situational
B. Maturational
C. Adventitious
D. Developmental
A. Situational
Rationale: This client situation is an example of a situational crisis which refers to loss or change that is
often unexpected.
B. Maturational
Rationale: A maturational crisis refers to a crisis involving new stages of growth and development.
C. Adventitious
Rationale: An adventitious crisis refers to a crisis such as a natural disaster or act of violence.
D. Developmental
Rationale: A developmental crisis refers to a crisis involving new stages of growth and development.
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client’s partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?
A. “Do not worry about that. Your wife will be fine.”
B. “I think you should calm down a little before you see your partner.”
C. “Why do you think the crash is your fault?”
D. “Tell me more about your feelings about what happened to your partner.”
D. “Tell me more about your feelings about what happened to your partner.”
Rationale: This response illustrates the therapeutic communication technique of exploring, and will encourage the client to express his feelings about his partner’s accident.
