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A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse?
- A. How is your spouse's new job going?'
- B. I've noticed that you seem frustrated lately.'
- C. It's normal to be angry when you can't work anymore.'
- D. We have a support group that can help you adjust to rehab.'
Correct Answer: B
Rationale: Acknowledging observed behavior (B) opens a therapeutic conversation and validates the client's feelings. Asking about the spouse's job (A), assuming anger (C), or suggesting a support group (D) may not address the client's current emotional state.
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A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.
- A. Document this communication in the electronic health record
- B. Encourage the client to discuss this decision with the health care proxy
- C. Facilitate completion of an advance directive that reflects the client's decision
- D. Obtain a signed informed consent from the client
- E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
Correct Answer: A, B, C
Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
- A. Dimming the lights at night
- B. Leaving the television on for diversion at night
- C. Opening the window blinds/shades in the morning
- D. Scheduling interventions and activities during the day when possible
- E. Turning off equipment alarms in the client's room at night
Correct Answer: A, C, D
Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.
A client is to be discharged following the removal of a cataract on the right eye. The nurse should tell the client to:
- A. Wear the metal eye shield only during waking hours.
- B. Report any eye pain to the doctor immediately.
- C. Refrain from using a pillow under his head.
- D. Avoid wearing dark glasses inside.
Correct Answer: B
Rationale: Reporting eye pain immediately is critical as it may indicate complications like infection or increased intraocular pressure. The eye shield is typically worn at night or as directed. Using a pillow is not contraindicated. Dark glasses are often recommended to reduce glare.
The nurse is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse administer to the client? Select all that apply.
- A. albuterol
- B. buproten
- C. ipratropium
- D. tobramycin
- E. montelukast
Correct Answer: A, C
Rationale: Albuterol (A) and ipratropium (C) are bronchodilators used in acute asthma exacerbations. Ibuprofen (B), tobramycin (D), and montelukast (E) are not indicated for acute management.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.