The nurse observes an 8-year-old child regressing to behavior that is characteristic of a toddler when faced with new situations. The child has been in several foster care families over the past three years
Which of the following interventions is appropriate for this child? 1. Providing for unmet needs
2. Providing consistency and continuity of caregivers
3. Ignoring the regressive behavior
4. Ignoring the negative behavior and reinforcing the positive behavior
2
Rationale: Defense mechanisms commonly employed by children are repression, reaction formation, and projection. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. Providing the child with consistency and continuity of caregivers will minimize situations that stimulate regression. The nurse will be able to evaluate the client's response to having consistency and continuity of caregivers. The nurse must recognize this behavior as a defense mechanism, and plan care that will strengthen the child's coping mechanisms. Providing for unmet needs is not specific or individualized and will be difficult to measure.
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A child has had a heart transplant. The nurse recognizes that postoperative teaching has been successful when the parents state that the child is on cyclosporin A to:
1. Reduce serum cholesterol level. 2. Prevent rejection. 3. Treat hypertension. 4. Treat infections.
The nurse expects to observe the following manifestations of metabolic acidosis upon physical assessment of the client:
1. Carpopedal spasm 2. Convulsions 3. Kussmaul's breathing 4. Hyperventilation
A nurse is facilitating a group for family members of recently diagnosed Alzheimer's patients. Which of the nurse's following teaching points about the etiology of Alzheimer's disease is most accurate?
A) "There are a number of factors that cause Alzheimer's disease, and modification or removal of many of these can cause a significant improvement in your loved one's condition.". B) "Unfortunately we still do not really know anything about what exactly causes Alzheimer's.". C) "Science has recently discovered the direct link between diet and the development of Alzheimer's disease.". D) "Alzheimer's appears to result from a combination of genetic and environmental factors and no one theory can explain it.".
The nurse counsels a 52-year-old male patient who returns for a follow-up visit 3 weeks after starting an alpha antagonist for hypertension. He is upset because the medication has caused problems with ejaculation
The nurse's best response would be: a. "The problem will be resolved when the drug is discontinued. If this is unacceptable to you, you will need a different drug." b. "The ejaculatory problem is probably a result of your hypertension and thus is likely to be permanent." c. "The ejaculatory problem is not as important as uncontrolled hypertension. You will need to cope with this problem." d. "You should stay on the medication for 12 months before changing regardless of the side effects."