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A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. "You have nothing to worry about. You are in a safe place. Try to relax."?
- B. "Has anything happened recently or in the past that might have triggered these feelings?"?
- C. "We have given you a medication that helps to decrease feelings of anxiety."?
- D. "Take some deep breaths and try to calm down."?
Correct Answer: B
Rationale: Choice B is the best response as it shows empathy, acknowledges the patient's feelings, and opens the door for discussion about potential triggers for anxiety. This approach helps the patient explore the root cause of his anxiety and provides an opportunity for therapeutic communication. Choice A dismisses the patient's feelings and offers false reassurance, which may not address the underlying issue. Choices C and D do not encourage the patient to express his emotions or delve into the reasons behind his anxiety, hindering the therapeutic process.
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If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the dialysate
- D. Obtain a complete blood count
Correct Answer: B
Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.
In which age group does the highest incidence of child abuse occur?
- A. Birth-3 years old
- B. 4-6 years old
- C. 6-10 years old
- D. More than 10 years old
Correct Answer: A
Rationale: The correct answer is 'Birth-3 years old.' Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). This age group is most vulnerable due to their dependency and inability to report or protect themselves effectively. Child abuse can occur at any age, but statistics show that infants and toddlers are at the highest risk due to their developmental stage and reliance on caregivers. Choices B, C, and D are incorrect because while child abuse can happen at any age, the prevalence is highest among children in the 0-3 age group.
Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?
- A. High-fiber
- B. Low-residue
- C. Bland
- D. Clear-liquid
Correct Answer: D
Rationale: The correct answer is 'Clear-liquid.' After a hemorrhoidectomy, the client is usually started on a clear-liquid diet to allow the intestines to rest and promote healing. This diet helps prevent straining during bowel movements, which is crucial for recovery. Stool softeners are often included in the plan to avoid constipation. Once the client tolerates the clear liquids well, they can progress to a regular diet. High-fiber diet (choice A) is beneficial in the later stages of recovery to prevent constipation but is not typically the initial post-operative diet. Low-residue diet (choice B) and bland diet (choice C) are not appropriate for this type of surgery as they may not provide the necessary post-operative care and support needed for healing.
A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
- A. A client with brain attack (stroke) receiving tube feedings
- B. A client with congestive heart failure complaining of nighttime dyspnea
- C. A client who had a thoracotomy 6 months ago
- D. A client with Parkinson’s disease
Correct Answer: B
Rationale: The correct answer is B. The client with congestive heart failure complaining of nighttime dyspnea should be seen first as airway management is a priority in nursing care. This client's symptoms indicate potential respiratory distress, requiring immediate attention. Choices A, C, and D involve clients who are more stable and do not present with urgent or acute conditions that require immediate intervention. Choice A with a client receiving tube feedings for a stroke may require attention, but the urgency of addressing potential respiratory distress in choice B takes precedence. Choice C, a client who had a thoracotomy 6 months ago, unless presenting with acute distress, does not necessitate immediate attention. Choice D, a client with Parkinson's disease, is usually a chronic condition that does not typically require immediate intervention for the described scenario.
A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?
- A. "I will ask the physician to prescribe medication for you."?
- B. "That must have been a very difficult and frightening experience. It might be helpful to talk about it."?
- C. "In the future, you might walk your dog in a more populated area or hire someone else to take over this task."?
- D. "Have you thought of moving to a safer neighborhood?"?
Correct Answer: B
Rationale: Choice B is the best response as it provides empathy and encourages the client to talk about her experience, which can be therapeutic. This approach validates the client's feelings and offers support. By acknowledging the difficulty and fear experienced by the client, the nurse opens the door for the client to express her emotions and begin the process of coping with the trauma. Choices A, C, and D do not address the emotional impact of the traumatic event or provide an opportunity for the client to express her feelings and concerns. Choice A immediately jumps to medication without exploring other supportive interventions. Choice C focuses on practical solutions without addressing the client's emotional needs. Choice D suggests a drastic solution without considering the client's emotional state or preferences.