Nokea
A client diagnosed with angina pectoris appears to be very anxious and states, 'So, I had a heart attack, right?' Which response should the nurse make to the client?
- A. No. That is not why you are hospitalized.'
- B. No, but there could be some minimal damage to your heart.'
- C. No, not this time and we will do our best to prevent a future heart attack.'
- D. No, but it's necessary to monitor you and control or eliminate your pain.'
Correct Answer: D
Rationale: Angina pectoris occurs as a result of an inadequate blood supply to the myocardium causing pain; managing the condition will help address the client's pain. The nurse will want to correct the client's misconception regarding a heart attack while addressing the client's concerns. Option 1 does not address the client's concerns. Option 2 is not correct because angina involves interrupted blood supply but does not result in cardiac tissue damage. Neither the nurse nor the primary health care provider can guarantee that a heart attack will not occur as option 3 seems to indicate.
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The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?
- A. Do you have concerns about managing your condition?'
- B. Do you think you might need to go to the nursing home?'
- C. If you take the correct medications, I doubt this will happen again.'
- D. Don't worry. I'm sure your family will provide all the help you need.'
Correct Answer: A
Rationale: The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in the correct option. Option 2 is not an appropriate nursing response because it is making suggestions regarding care options without appropriately identifying the client's true concerns. Options 3 and 4 provide inappropriate false hope and disregard the client's concerns.
A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse's ability to use therapeutic communication techniques to effectively assess the teenager's feelings about using a cane?
- A. How do you feel about needing a cane to walk?'
- B. Do you have questions about ambulating with a cane?'
- C. Are you worried about what your friends will think about your cane?'
- D. What types of problems do you think you'll have ambulating with a cane?'
Correct Answer: A
Rationale: The nurse effectively uses therapeutic communication techniques when posing an open-ended question to elicit assessment data about how the teenager feels about using a cane. The remaining options are closed-ended questions. Option 3 makes assumptions about how the teenager feels, and options 2 and 4 focus on the physical aspects of using the cane.
The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, 'I don't think that this ECT will be helpful, especially since it makes people's memory worse.' What form of communication should the nurse implement to address the family member's concern?
- A. Ask other family members and the client if they think that ECT makes people worse.
- B. Immediately reassure the client and family that ECT will help and that the memory loss is only temporary.
- C. Involve the family member in a dialog to ascertain how the family member arrived at this conclusion.
- D. Reinforce with the client and the family member that depression causes more memory impairment than ECT.
Correct Answer: C
Rationale: Involving the family member in a dialog allows the nurse to understand their concerns and provide accurate information about ECT, addressing misconceptions about memory loss. Option 1 shifts focus away from the family member's concern, option 2 provides premature reassurance without exploring the concern, and option 4 makes an assumption about the cause of memory impairment without addressing the family member's specific worry.
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
- A. The nurse and client determine the contract for time.
- B. The client is encouraged to make use of all services depending on need.
- C. The client begins to identify with the nurse, and trust and rapport are maintained.
- D. The nurse focuses on facilitating the therapeutic expression of the client's feelings.
Correct Answer: A
Rationale: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse-client relationship.
A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?
- A. Open-ended questions and silence
- B. Offering personal opinions about the need to eat
- C. Verbalizing reasons why the client may choose not to eat
- D. Focusing on self-disclosure of the nurse's own food preferences
Correct Answer: A
Rationale: Open-ended questions and silence are strategies that are used to encourage clients to discuss their feelings in a descriptive manner. Options 2 and 3 are not helpful to the client because they do not encourage the expression of personal feelings. Option 4 is not a client-centered intervention.