Nokea
A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?
- A. Guided imagery and limiting fluids
- B. Relaxation and breathing techniques
- C. Biofeedback and coughing techniques
- D. Distraction and increased dietary carbohydrates
Correct Answer: B
Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.
You may also like to solve these questions
The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse?
- A. Physical contact should be avoided whenever possible.
- B. The spouse would not feel or be harmed by the countershock.
- C. The shock would be felt, but it would not cause the spouse any harm.
- D. A warning device sounds before countershock, so there is time to move away.
Correct Answer: C
Rationale: Clients and families are often fearful about the activation of the ICD. Their fears are about the device itself and also about the occurrence of life-threatening dysrhythmias that trigger its function. Family members need reassurance that, even if the device activates while they are touching the client, the level of the charge is not high enough to harm the family member, although it will be felt. The ICD emits a warning beep when the client is near magnetic fields, which could possibly deactivate it, but it does not beep before countershock.
The nurse talks with a child who has been sexually abused by a family member. The child asks the nurse, 'If I tell you something, will you tell anyone my secret?' Which response by the nurse to the client is appropriate?
- A. I will not tell anyone your secret.
- B. I will not tell your mom and dad.
- C. I'll call the nursing supervisor as a witness.
- D. I cannot keep this information a secret.
Correct Answer: D
Rationale: Nurses are mandated reporters and cannot promise confidentiality in cases of abuse, as reporting to authorities is required to protect the child. This response is honest and maintains trust while adhering to legal and ethical obligations.
The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect?
- A. The client's blood pressure is 180/96 mm Hg.
- B. The client has right-sided weakness.
- C. The client has tinnitus.
- D. The client invents elaborate, improbable events.
Correct Answer: D
Rationale: Korsakoff psychosis, often linked to chronic alcoholism, is characterized by confabulation, where clients invent elaborate but false events to fill memory gaps. Hypertension, weakness, or tinnitus are not specific to this condition.
Which comment made by the parents of a male infant who will have a surgical repair of a hernia indicates a need for further teaching by the nurse?
- A. I understand that surgery will repair the hernia.'
- B. I don't know if he will be able to father a child when he grows up.'
- C. The day nurse told me to give him sponge baths for a few days after surgery.'
- D. I'll need to buy extra diapers because we need to change them frequently now.'
Correct Answer: B
Rationale: The anatomical location of a hernia frequently causes more psychological concern to the parents than does the actual condition or treatment. The remaining options all indicate accurate understanding associated with the surgery. The correct option is an incorrect comment requiring follow-up.
The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed?
- A. Psychodrama
- B. Reality therapy
- C. Psychoanalytic therapy
- D. Short-term dynamic psychotherapy
Correct Answer: A
Rationale: Psychodrama involves the enactment of emotionally charged situations. Reality therapy is used for individuals with cognitive impairment. Both short-term dynamic psychotherapy and psychoanalytic therapy depend on techniques that are drawn from psychoanalysis.