Nokea
A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?
- A. Remaining with the client
- B. Placing the client in a quiet room
- C. Teaching the client deep-breathing exercises
- D. Encouraging the expression of feelings and concerns
Correct Answer: A
Rationale: If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
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When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?
- A. Autopsies are mandatory for clients who are DOA.'
- B. Federal law requires autopsies for clients who are DOA.'
- C. The medical examiner makes the decision about autopsies.'
- D. I will make sure the medical examiner is aware of your request.'
Correct Answer: D
Rationale: The nurse should notify the medical examiner or the coroner when a family wishes to avoid having an autopsy on a deceased family member. Normally the medical examiner will honor the family request unless there is a state law requiring the autopsy. Depending on the state, it is not mandatory for every client who is DOA to have an autopsy. However, many states require an autopsy in specific circumstances, including sudden death, a suspicious death, and death within 24 hours of admission to the hospital. Autopsy is not a requirement under federal law.
The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach should the nurse use to help the family cope with their concerns?
- A. Explain equipment and procedures on an ongoing basis.
- B. Discuss displaying their grief only when not in the room with the client.
- C. Discourage them from touching the client in order to minimize stimulation.
- D. Explain that they need their rest so they should adhere to regular visiting hours.
Correct Answer: A
Rationale: Families often need assistance to cope with the sudden severe illness of a loved one. The nurse should explain all equipment, treatments, and procedures, and he or she should supplement or reinforce the information given by the primary health care provider. Displaying grief is a normal process and should not be discouraged. The family should be encouraged to touch and speak to the client and become involved in the client's care in some way if they are comfortable with doing so. The nurse should allow the family to stay with the client whenever possible. This is important for both the client and the family.
The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?
- A. Placing the client in a private room to ensure privacy and confidentiality
- B. Interacting with the client demonstrating examples of unconditional positive regard
- C. Maintaining a distance of 10 inches in order to ensure the client that personal control will be provided
- D. Placing the client in charge of a meaningful unit activity, such as the morning chess tournament
Correct Answer: B
Rationale: The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and the client's thinking are unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. The client would not be placed in a private room because this is an unsafe action that may intensify the client's feelings of worthlessness. Distance of 18 inches or less between two individuals constitutes intimate space. The invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness. Placing the client in charge of the morning chess tournament is a premature intervention that can overwhelm the client and cause the client to fail; this can reinforce the client's feelings of worthlessness.
A stillborn baby was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. The registered nurse is orienting a new nurse, and has provided education on how to communicate with the family. Which statement by the new nurse indicates that teaching has been effective?
- A. How can I assist you with ways to remember your baby?'
- B. You seem upset. Do you think a tranquilizer would help?'
- C. I feel so bad. I don't understand why this happened either.'
- D. I can allow another 15 minutes together for you to grieve.'
Correct Answer: A
Rationale: Nurses should be able to explore measures that assist the family with creating memories of the infant so that the existence of the child is confirmed, and the parents can complete the grieving process. The correct option identifies this measure and also demonstrates a caring and empathetic client-focused response while providing the family with the option to express their needs. Option 2 devalues the parents' feelings and is inappropriate. Option 3 is inappropriate and reflects a lack of knowledge on the nurse's part. Option 4 appears that the nurse is uncaring.
The nurse cared for a client who died a few minutes ago. Which event supports the nurse's belief that the client died with dignity?
- A. The family thanks the nurse for facilitating such a peaceful death.
- B. The nurse states that it is difficult to give that kind of care to a dying client.
- C. The primary health care provider acknowledges that all of the prescriptions were carried out.
- D. The nurse kept the client's last hours comfortable with increasing doses of pain medication.
Correct Answer: A
Rationale: The family response is an external perception, and it is extremely important. Families derive a great deal of comfort from knowing that their loved one received the best care possible. The correct option provides external validation that the client received comprehensive, quality care. Option 2 focuses on the feelings of the nurse, who may be expressing his or her own anxiety. Option 3 focuses on the provider's prescriptions rather than client care. Option 4 reflects on only one aspect of the care of a dying client.