Nokea
A client diagnosed with hyperaldosteronism has developed kidney failure and states to the nurse, 'This means that I will die very soon.' Which is the most appropriate therapeutic response for the nurse to make to the client?
- A. You will do just fine.
- B. What are you thinking about?
- C. You sound discouraged today.
- D. I read that death is a beautiful experience.
Correct Answer: B
Rationale: The therapeutic response encourages the client to express their thoughts and feelings about their prognosis, facilitating open communication. Option 1 provides false reassurance, which can block communication. Option 3 labels the client's emotions without encouraging further exploration. Option 4 is inappropriate and does not address the client's specific concerns about their condition.
You may also like to solve these questions
A client diagnosed with nephrotic syndrome asks the nurse, 'Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do if I can never get rid of this kidney problem, anyway!' Which should the nurse identify as the most appropriate concern for this client?
- A. Anxiety
- B. Powerlessness
- C. Difficulty coping
- D. Negative self-image
Correct Answer: B
Rationale: Powerlessness is present when the client believes that personal actions will not affect an outcome in any significant way. Because nephrotic syndrome is progressive, the client may feel that personal actions may not affect the disease process. Anxiety is appropriate when the client has a feeling of unease with a vague or undefined source. Difficulty coping occurs when the client has impaired adaptive abilities or behaviors with regard to meeting expected demands or roles. Negative self-image is when there is an alteration in the way that the client perceives his or her body image.
During an office visit, a prenatal client diagnosed with mitral stenosis states being under a lot of stress lately. During the examination, the client questions the nurse about the assessment and behaves anxiously. Which is the appropriate nursing action at this time?
- A. Tell the client not to worry.
- B. Refer the client to a counselor.
- C. Assume that the client's anxiety will lessen when the assessment is finished.
- D. Explain the purpose of the nurse's actions and answer the client's questions.
Correct Answer: D
Rationale: In the prenatal cardiac client, stress should be reduced as much as possible. The client should be provided with honest and informed answers to questions to help alleviate unnecessary fears and emotional stress. Explaining the purpose of nursing actions will assist with decreasing the stress level of the client. The remaining options are nontherapeutic because they neglect to deal with the client's concerns.
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a diagnosis of major depressive disorder. Which assessment findings should the nurse identify as expected short-term side effects of ECT that do not require notifying the primary health care provider?
- A. Confusion
- B. Memory loss
- C. Hypertension
- D. Disorientation
- E. Heart palpitations
Correct Answer: A,B,D
Rationale: The major expected side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure or presence of heart palpitations would not be anticipated side effects and would be causes for concern. If hypertension or presence of heart palpitations occurred after ECT, the primary health care provider should be notified.
A client who is quadriplegic frequently makes lewd sexual suggestions and uses profanity. The nurse concludes that the client is inappropriately using displacement. Which concern should the nurse identify as being appropriate for this client?
- A. Disuse syndrome
- B. Lack of coping skills
- C. Negative body image
- D. Lack of awareness of surroundings
Correct Answer: B
Rationale: Lack of coping skills is evident when the client demonstrates an impaired ability to adapt to meeting life's demands and roles. This client is displacing feelings onto the environment instead of using them in a constructive fashion. Option 3 may be appropriate, but it has nothing to do with the displacement that the client is currently using. Options 1 and 4 have no relation to this situation.
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.