HESI COMPREHENSION EXAM 4 Questions and Answers with Rationale

HESI COMPREHENSION EXAM 4 1.A client in a manic state emerges from her room and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. The priority nursing action is to: Ask the client to go to her room and to change her clothes Tell the client firmly that burlesque shows are not allowed in the nursing unit Tell the client that her bathroom privileges are being suspended because of her behavior Quietly and firmly assist the client to her room and help her dress in appropriate clothes Correct Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client’s bathroom privileges because of behavior, having the client change her clothes and telling the client that burlesque shows are not allowed in the nursing unit will all increase the client’s anxiety. Test-Taking Strategy: Focus on the data provided in the question. Note the strategic word “priority.” Recalling that protecting the client is a primary nursing responsibility will direct you to the correct option. Review care of the client with mania if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 355 ). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 2.ID: A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? "Do you think that having asthma will kill you?" "You seem very distressed at learning that you have asthma." Correct "I'm not going to work with you if you can't view this as a challenge rather than a ‘nail in your coffin.’” "Asthma is a very treatable condition, but it’s important to learn how to properly administer your medications. Let's practice with your inhalant." Incorrect Rationale: A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with such illnesses. It is important for the nurse to convey an accepting attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed at learning that you have asthma" paraphrases the client’s words and focuses on the client’s feelings. "Do you think that having asthma will kill you?" reflects and paraphrases the client’ s words but is somewhat sarcastic. "Asthma is a very treatable condition, but it’s important to learn how to properly administer your medications. Let's practice with your inhalant" lectures the client and does not deal directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge rather than as a ‘nail in your coffin’” is punitive, threatens the client, and sarcastically quotes the client’ s words. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Remembering the need to focus on the client’ s feelings will direct you to the correct option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 613, 615). St. Louis: Saunders. Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points.