Nokea
A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will be required. The client becomes angry and states, 'I'll never be the same now.' Based on this information, which should the nurse identify as the client's primary concern?
- A. Anxiety about the hemodialysis
- B. Inability to think clearly because of the treatments needed
- C. Potential for noncompliance because of concerns about the disease
- D. Altered body image because of the physical changes that may occur
Correct Answer: D
Rationale: A client with a renal disorder such as CKD may become angry in response to the permanence of the condition. Because of the physical changes and the change in lifestyle that may be required to manage a severe renal condition, the client may experience an altered body image. Anxiety is not appropriate because the client is exhibiting anger at this time. The client is not cognitively impaired, eliminating option 2, and is not stating a refusal to undergo therapy, so eliminate option 3.
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The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
- A. The process of grief is detrimental to physical and emotional health.
- B. Age, gender, and culture are a few factors that influence the grieving process.
- C. The nurse must explore his own feelings about death before he may effectively help others.
- D. The nurse should discourage expression of grief and loss because it may upset other clients nearby.
- E. The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one.
Correct Answer: B,C,E
Rationale: Grief is influenced by age, gender, and culture (B), nurses must process their own feelings about death (C), and helping families cope with loneliness/depression (E) is appropriate. Grief is not inherently detrimental (A), and discouraging expression (D) is counterproductive.
A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement?
- A. A brain tumor presents with few sights/symptoms.
- B. It is true that brain tumors are easily recognizable.
- C. Brain tumors are never detected until very late in their course.
- D. The signs/symptoms of a brain tumor may be easily attributed to another cause.
Correct Answer: D
Rationale: Signs and symptoms of a brain tumor vary depending on location, and they may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and changes in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them during the normal grieving process. Options 1, 2, and 3 are inaccurate statements.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
- A. Monitor vital signs every 15 minutes.
- B. Administer bromocriptine as prescribed.
- C. Administer the haloperidol as prescribed.
- D. Assess the client's level of consciousness.
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
- A. Do you want me to call your daughter?'
- B. Can you tell me a little about what has you so upset?'
- C. Try not to be so upset. Psychological stress is bad for your heart.'
- D. I understand how you feel. I'd cry, too, if I had a major heart attack.'
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.