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A client awaiting surgery expresses fear of having cancer. Which response by the nurse is most appropriate?
- A. "Why do you think you have cancer?"
- B. "I don't see any reason for you to worry."
- C. "That's something to discuss with your provider."
- D. "I hear that you are concerned about this."
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the client's feelings and shows empathy. By saying, "I hear that you are concerned about this," the nurse validates the client's emotions and creates a supportive environment. Choice A is incorrect as it may come off as dismissive. Choice B is inappropriate as it invalidates the client's fear. Choice C passes the responsibility back to the client's provider instead of addressing the immediate concern.
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Where should a nurse assign a client experiencing manic behavior?
- A. Semi-private room across from the day room
- B. Private room in a quiet location
- C. Semi-private room across from the snack area
- D. Shared room near the nursing station
Correct Answer: B
Rationale: The correct answer is B: Private room in a quiet location. This choice is appropriate because a client experiencing manic behavior requires a calm and quiet environment to minimize stimulation and help reduce agitation. Placing the client in a private room can provide the necessary space for the client to calm down and prevent potential triggers for further manic episodes.
Other choices are incorrect:
A: A semi-private room across from the day room may expose the client to increased noise and activity, which can exacerbate manic behavior.
C: A semi-private room across from the snack area may lead to distractions and potential interactions that can escalate the manic behavior.
D: A shared room near the nursing station may not offer the privacy and quiet environment needed for a client experiencing manic behavior to stabilize.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
- A. "I check any room I enter because the enemy is still after me and could be hiding anywhere."
- B. "I killed four enemy soldiers with my bare hands and saved my entire battalion."
- C. "My child was born with a birth defect due to an exposure I had overseas."
- D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Correct Answer: D
Rationale: The correct answer is D because the statement indicates the client is experiencing intrusive memories and nightmares, which are common symptoms of PTSD. This suggests the client is reliving the traumatic event. Choice A suggests hypervigilance, which can be a symptom of PTSD but is not as specific as intrusive memories. Choice B indicates possible grandiosity or exaggerated sense of self-importance. Choice C suggests guilt related to a different issue. Summarily, choices A, B, and C do not directly align with the hallmark symptoms of PTSD like choice D does.
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect?
- A. Dismissal of past failures
- B. Psychomotor agitation
- C. An increase in energy
Correct Answer: B
Rationale: The correct answer is B: Psychomotor agitation. In major depressive disorder, psychomotor agitation is a common symptom characterized by restlessness, pacing, fidgeting, or hand-wringing. This is due to the increased inner tension and anxiety experienced by the individual. Dismissal of past failures (A) is not a typical finding in major depressive disorder, as individuals often dwell on negative thoughts. An increase in energy (C) is unlikely, as fatigue and low energy levels are more common in depression. The other choices are not provided, but it's important to remember that psychomotor agitation can be a key indicator in identifying major depressive disorder.
A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make?
- A. "Why would you want to put your partner's health at further risk?"
- B. "You will need to discuss your concerns about your partner's diet with the provider."
- C. "Everyone likes food from home, but it can delay your partner's recovery."
- D. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
Correct Answer: D
Rationale: The correct answer is D: "Let's try to find ways to incorporate your partner's favorite food into her diet plan." This response acknowledges the partner's desire to bring food from home while also emphasizing the importance of adhering to the client's dietary plan for recovery. By suggesting a compromise to incorporate the favorite food within the diet plan, the nurse is promoting collaboration and patient-centered care. It shows understanding and empathy towards the partner's concerns while prioritizing the client's health and recovery.
Choice A is incorrect as it may come off as judgmental and dismissive. Choice B is not the most appropriate response as it doesn't address the partner's request directly. Choice C is incorrect as it may sound like a blanket statement and could potentially create tension between the nurse and the partner.
A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
- A. "I will have your provider discuss the adverse effects with you before the treatment begins."
- B. "Someone from the American Cancer Society will be here soon to answer your questions."
- C. "What is it about the adverse effects that concern you?"
- D. "I agree. Sometimes the adverse effects can be worse than the disease."
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should respond with "What is it about the adverse effects that concern you?" This response shows empathy, encourages open communication, and allows the nurse to address the client's specific fears or concerns. It also promotes a patient-centered approach to care, enhancing trust and rapport between the nurse and the client. This response demonstrates active listening and provides an opportunity for individualized education and support.
Incorrect Answers:
A: This response defers the responsibility to the provider and does not address the client's concerns directly.
B: This response does not address the client's specific concerns and may not provide the necessary support.
D: This response dismisses the client's concerns and does not address the root of her worries, potentially increasing anxiety.
E, F, G: No information provided.