Nokea
A client diagnosed with diabetes mellitus requires the immediate amputation of a leg. The client is very upset and states, 'This is the doctor's fault! I did everything that I was told to do!' When considering the grieving process, how should the nurse respond to the client's statement?
- A. Notify the agency's risk management department.
- B. Help the client consider alternatives to treatment.
- C. Allow the client to use anger as a coping mechanism.
- D. Ask the client to list all previous health care providers.
Correct Answer: C
Rationale: Anger is a stage in the grieving process and an expected response to impending loss. Usually a client directs the anger toward himself or herself, God or another spiritual being, or the caregivers; thus far the client's behavior demonstrates effective coping. Notifying the risk management department is premature, especially because the client has said nothing about legal action. Analyzing alternative treatment options and previous health care providers is likely to interfere with effective coping, and it can delay lifesaving treatment.
You may also like to solve these questions
When a client is dead on arrival (DOA) to the emergency department, the family states that they do not want an autopsy performed. Which statement should the nurse make in response to the family?
- A. Autopsies are mandatory for clients who are DOA.'
- B. Federal law requires autopsies for clients who are DOA.'
- C. The medical examiner makes the decision about autopsies.'
- D. I will make sure the medical examiner is aware of your request.'
Correct Answer: D
Rationale: The nurse should notify the medical examiner or the coroner when a family wishes to avoid having an autopsy on a deceased family member. Normally the medical examiner will honor the family request unless there is a state law requiring the autopsy. Depending on the state, it is not mandatory for every client who is DOA to have an autopsy. However, many states require an autopsy in specific circumstances, including sudden death, a suspicious death, and death within 24 hours of admission to the hospital. Autopsy is not a requirement under federal law.
A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time?
- A. Remaining with the client
- B. Placing the client in a quiet room
- C. Teaching the client deep-breathing exercises
- D. Encouraging the expression of feelings and concerns
Correct Answer: A
Rationale: If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?
- A. Placing the client in a private room to ensure privacy and confidentiality
- B. Interacting with the client demonstrating examples of unconditional positive regard
- C. Maintaining a distance of 10 inches in order to ensure the client that personal control will be provided
- D. Placing the client in charge of a meaningful unit activity, such as the morning chess tournament
Correct Answer: B
Rationale: The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and the client's thinking are unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. The client would not be placed in a private room because this is an unsafe action that may intensify the client's feelings of worthlessness. Distance of 18 inches or less between two individuals constitutes intimate space. The invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness. Placing the client in charge of the morning chess tournament is a premature intervention that can overwhelm the client and cause the client to fail; this can reinforce the client's feelings of worthlessness.
A client diagnosed with Parkinson's disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client's activities of daily living. Which statement indicates that the teaching has been effective?
- A. We should plan for only a few activities during the day.'
- B. We should assist with activities of daily living as much as possible.'
- C. We should cluster activities at the end of the day, to help conserve energy.'
- D. We should encourage and praise efforts to exercise and perform activities of daily living.'
Correct Answer: D
Rationale: The client with Parkinson's disease has a tendency to become withdrawn and depressed, which can be limited by encouraging the client to be an active participant in his or her own care. The family should plan activities intermittently throughout the day to inhibit daytime sleeping and boredom. The family should also give the client encouragement and praise for his or her perseverance in these efforts and help only when necessary.
The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, 'If this is a stroke, it's the kiss of death.' What initial response should the nurse make?
- A. Why would you think like that?'
- B. You feel your mother is dying?'
- C. These symptoms are reversible.'
- D. A stroke is not the kiss of death.'
Correct Answer: B
Rationale: Option 2 allows the daughter to verbalize her feelings, begin coping, and adapt to what is happening. By restating, the nurse seeks clarification of the daughter's feelings and offers information that potentially helps ease some of the fears and concerns related to the client's condition and prognosis. Option 1 is a disapproving comment that is likely to interfere with communication. Option 3 is potentially misleading and offers false hope. The nurse could reflect back the statement in option 4 to the daughter to promote communication. However, as it stands, option 4 is a barrier to communication that contradicts the daughter's feelings.