Nokea
A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?
- A. Reports the client to the police for illegal drug use
- B. Explains to the client the damage that cocaine does to the heart
- C. Tells the client it is imperative to stop before myocardial infarction occurs
- D. Teaches about the effects of cocaine on the heart and offers a referral for further help
Correct Answer: D
Rationale: In this scenario, the nurse should prioritize educating the client about the effects of cocaine on the heart and provide a referral for further help. This approach is crucial in addressing the root cause of the client's health issues and supporting them in making informed decisions about their health. Reporting the client to the police or simply explaining the damage without offering solutions may not effectively address the client's needs or promote holistic care.
You may also like to solve these questions
The healthcare provider is monitoring a client with left-sided heart failure. Which assessment finding indicates that the client's condition is worsening?
- A. Clear lung sounds
- B. Increased peripheral pulses
- C. Bibasilar crackles
- D. Improved activity tolerance
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?
- A. Shave the front of the client's chest
- B. Give the client a device holder to wear around the waist
- C. Teach the client to rest as much as possible during the next 24 hours
- D. Tell the client to cover the monitor in plastic wrap before taking a bath
Correct Answer: B
Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings.
While preparing a client for a cardiac catheterization, the client expresses a preference to speak with their doctor rather than the nurse. Which response by the nurse should be therapeutic?
- A. Your doctor expects me to prepare you for this procedure.
- B. That's fine, if that's what you want. I'll call your health care provider.
- C. So you're saying that you want to talk to your health care provider?
- D. I'm concerned with the way you've dismissed me. I know what I am doing.
Correct Answer: C
Rationale: The therapeutic response by the nurse in this situation involves reflecting the client's feelings back to them, which demonstrates active listening and empathy. By restating the client's preference to talk to their doctor, the nurse acknowledges and validates the client's feelings, thereby fostering a positive therapeutic relationship and promoting open communication.
The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?
- A. Take daily weights and monitor trends.
- B. Encourage fluid intake to improve hydration.
- C. Elevate the legs above the level of the heart.
- D. Position the client supine with the head of the bed at 30 degrees.
Correct Answer: A
Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early.
The healthcare provider notes this rhythm on the client's cardiac monitor. The healthcare provider next reports that the client is experiencing which heart rhythm?
- A. Normal sinus
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.