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A client awaiting surgery for the removal of a pancreatic mass shares with the nurse concerns about not waking up after receiving the anesthesia. Which therapeutic response is most appropriate for the nurse to make to the client?
- A. This is a very common concern.
- B. Tell me what makes you feel concerned about the anesthesia.
- C. I had surgery a year ago and was afraid of the same thing. I did just fine.
- D. You have the best anesthesiologist in this hospital. There is no need to be scared.
Correct Answer: B
Rationale: This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic response to the client is the one that encourages the client to express her or his concerns. Option 1 is a stereotypical response. Option 3 avoids the client's concern and focuses on the nurse's personal experience. Option 4 also avoids the client's concern.
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Which psychosocial factor obtained during an assessment of an older client places the client most at risk for abuse?
- A. The client resides in an apartment in a low-income neighborhood.
- B. The client shows several signs and symptoms of clinical depression.
- C. The client is completely dependent on family members for both food and medicine.
- D. The client has been diagnosed with and is being treated for several chronic illnesses.
Correct Answer: C
Rationale: Elder abuse is sometimes the result of frustrated adult children who find themselves caring for dependent parents. Increasing demands by parents for care and financial support can cause resentment and a feeling of being burdened. The issues of abuse are not bound to socioeconomic status (option 1). Option 2 relates to depression rather than the risk for abuse. Option 4 relates to a physical factor rather than a psychosocial factor.
The nurse is planning interventions for counseling a maternal client who has been newly diagnosed with sickle cell anemia. Which would be the most important psychosocial intervention at this time?
- A. Help the client identify her concerns.
- B. Avoid discussing the details of the disease.
- C. Allow the client to be alone if she is crying.
- D. Encourage family and friends to visit the client frequently.
Correct Answer: A
Rationale: One of the most important nursing roles is providing emotional support to the client and family during the counseling process. Option 2, like option 4, is nontherapeutic. Option 3 is only appropriate if the client requests to be alone; if this is not requested, the nurse is abandoning the client in a time of need. Option 4 overwhelms the client with information while she is trying to cope with the news of the disease.
During the admission assessment of a client with a history of alcohol abuse for diagnosis of ruptured esophageal varices, the client says, 'I deserve this. I brought it on myself.' Which response is most therapeutic for the nurse to make to the client?
- A. Would you like to talk to the chaplain?
- B. Is there some reason you feel you deserve this?
- C. Not all esophageal varices are caused by alcohol.
- D. That is something to think about when you leave the hospital.
Correct Answer: B
Rationale: Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic alcohol abuse. It is important to obtain an accurate history regarding the client's alcohol intake. If the client is ashamed or embarrassed, he or she may not respond accurately. Option 2 is open-ended and allows the client to discuss his or her feelings about drinking. Option 1 blocks the nurse-client communication process. Options 3 and 4 are somewhat judgmental.
A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring?
- A. The client has a home health aide coming to the house for 9 weeks.
- B. The client was going to stay with a daughter in the daughter's home indefinitely.
- C. The client was going to have blood work drawn in the home by a local laboratory.
- D. The client has a good friend living next door who would take the client to the doctor.
Correct Answer: B
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Option 2 provides a direct support system. Clients may need support systems in place to enhance compliance with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care.
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on?
- A. The financial status of the client
- B. Postoperative communication techniques
- C. Information given to the client by the surgeon
- D. The client's support systems and coping behaviors
Correct Answer: C
Rationale: The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation, but also to determine the starting point for teaching and to implement the education at the client's level. Although the remaining options may be components of the plan, they are not the initial focus.