Nokea
A client diagnosed with delirium anxiously states, 'Look at the spiders on the wall.' Which response by the nurse addresses the client's concerns therapeutically?
- A. Would you like me to kill the spiders for you?'
- B. While there may be spiders on the wall, they are not going to hurt you.'
- C. I know that you are frightened, but I do not see any spiders on the wall.'
- D. You are having a hallucination; I'm sure there are no spiders in this room.'
Correct Answer: C
Rationale: When hallucinations are present, the nurse should reinforce reality with the client while acknowledging the client's feelings as the correct option does. Eliminate options 1, 2, and 4 because they do not reinforce reality but rather support the legitimacy of the hallucination or that reinforces reality but does not address the client's feelings.
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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 assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?
- A. Phlebitis
- B. Infection
- C. Infiltration
- D. Thrombosis
Correct Answer: C
Rationale: The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV. All the remaining options are likely to be accompanied by warmth at the site.
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 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.
The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?
- A. Directing the discussions so that teaching needs are met
- B. Focusing directly on the client's message regarding needs
- C. Reflecting only facts related to the client's expressed concerns
- D. Reacting to the client's responses in a matter-of-fact, professional manner
Correct Answer: B
Rationale: For effective communication, the nurse uses active listening and assesses for verbal and nonverbal communication to receive the client's intended message, thus creating an environment in which the client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive, and it is unlikely to create an environment for the free exchange of thoughts and ideas. Reflecting facts only is a barrier to effective communication because subjective information can also provide a stimulus for effective communication. Reacting in a matter-of-fact manner can be an ineffective strategy for facilitating communication.