Nokea
A client diagnosed with angina pectoris is extremely anxious after being hospitalized. Which should the nurse do to minimize the client's anxiety?
- A. Provide care choices to the client.
- B. Keep the door open and the hallway lights on at night.
- C. Encourage the client to limit visitors to as few as possible.
- D. Arrange for the client to share a room with a cognitively alert client.
Correct Answer: A
Rationale: General interventions to minimize anxiety in the hospitalized client include providing information, social support, and control over choices related to care, as well as acknowledging the client's feelings. Leaving the door open with the hallway lights on may keep the client oriented, but these actions may interfere with sleep and increase anxiety. Limiting visitors reduces social support. The sharing of a room may not necessarily meet the client's needs.
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Which intervention does the nurse include in the plan of care for a client from a different culture?
- A. Being respectful of the client's needs.
- B. Expecting non-adherent behavior.
- C. Monitoring for difficulty with dietary restrictions.
- D. Offering a firm handshake upon leaving the client.
Correct Answer: A
Rationale: Respecting the client's cultural needs promotes trust and effective care, ensuring culturally sensitive interventions. Expecting non-adherence is biased, monitoring dietary restrictions is too specific, and a handshake may not be culturally appropriate.
A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?
- A. Suggest that the client arrange for help at home
- B. Ask the client to describe her concerns more fully
- C. Tell the client to speak to her primary health care provider about her concerns
- D. Recommend that the client schedule times when family members can assist her
Correct Answer: B
Rationale: When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.
When developing Jerry's plan of care, which of the following would NOT be helpful to include?
- A. Limiting choices
- B. Providing structure
- C. Encouraging patient input
- D. Ensuring availability of PRN medications
Correct Answer: A
Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.
The spouse of a dying client states to the nurse, 'I don't think I can come anymore and watch her die. It's chewing me up too much!' Which is the most therapeutic response the nurse should make to the spouse?
- A. It's hard to watch someone you love die. You've been here with your wife every day. Are you taking any time for yourself?
- B. Focus on your wife's pain rather than yours. I know it's hard, but this isn't about what's happening to you, you know.
- C. I know it's hard for you, but she would know if you're not there, and you would feel so very guilty all of the rest of your days.
- D. I think you're making the right decision. Your wife knows you love her. You don't have to come every day. I'll take care of her.
Correct Answer: A
Rationale: The most therapeutic response is the one that is empathetic and that reflects the nurse's understanding of the client's, in this case, the husband's, stress and emotional pain. In the correct option, the nurse suggests that the client take time for himself. Option 2 is an example of a nontherapeutic and judgmental attitude that places blame. Option 3 makes statements that the nurse cannot know are true (the client's wife may not in fact know if the husband visits), and it predicts feelings of guilt, which is inappropriate. Option 4 fosters dependency and gives advice, which is nontherapeutic.
A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.
- A. panic attacks
- B. impaired short-term memory
- C. auditory hallucinations
- D. inability to leave home
Correct Answer: A,D
Rationale: Agoraphobia involves panic attacks and fear of leaving safe environments, leading to inability to leave home. Memory issues and hallucinations are not typical.