Nclex Type Question

One of the goals the nurse and a client diagnosed with posttraumatic stress disorder (PTSD) mutually agreed upon is that the client will increase participation in out-of-the apartment activities. Which of the following recommendations, if made by the nurse, is MOST therapeutic to achieve this goal? 1. Take a day trip with a friend. 2. Take an 11-minute bus ride alone. 3. Join a support group, and participate in a victim assistance organization. 4. Take a 10-minute walk with the spouse around the block.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated
(2) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated
(3) correct—support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath
(4) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated

A client is scheduled for a traditional abdominal cholecystectomy. Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important? 1. "It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet." 2. "Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times." 3. "There will be a machine available to you after surgery for you to use to continuously receive pain medication." 4. "You may come back from surgery with a tube in your nose that drains your gallbladder."

Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired?
(1) not most important initially, teaching should be done before discharge
(2) correct—should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring
(3) PCA pumps used postoperative but medication administered intermittently
(4) NG tube used to drain stomach, T tube used to drain common bile duct

A mother of a 4-year-old boy comes to the prenatal clinic to confirm her second pregnancy. During the initial visit, it is MOST important for the nurse to take which of the following actions? 1. Assess the client's feelings about pregnancy, labor, and delivery. 2. Obtain a history of the client's last labor and delivery. 3. Determine how the client's 4-year-old feels about the pregnancy. 4. Identify the client's general health needs.

Strategy: Think about each answer choice.
(1) physical needs take priority
(2) physical needs take priority
(3) priority is taking care of pregnant client
(4) correct—optimal opportunity for preventive health maintenance