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A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring?
- A. The client has a home health aide coming to the house for 9 weeks.
- B. The client was going to stay with a daughter in the daughter's home indefinitely.
- C. The client was going to have blood work drawn in the home by a local laboratory.
- D. The client has a good friend living next door who would take the client to the doctor.
Correct Answer: B
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Option 2 provides a direct support system. Clients may need support systems in place to enhance compliance with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care.
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A client with the diagnosis of mania is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in the plan of care before seclusion?
- A. Ask the client if she understands why the seclusion is necessary.
- B. Remain silent because verbal interaction would be too stimulating.
- C. Tell the client that she will be allowed to come out when she can behave.
- D. Inform the client that she is being secluded to help regain her self-control.
Correct Answer: D
Rationale: Seclusion is a process in which a client is placed alone in a specially designed room for protection and close supervision. This client is removed to a nonstimulating environment as a result of her behavior. Options 1, 2, and 3 are nontherapeutic actions. Additionally, option 2 implies punishment. It is best to directly inform the client of the purpose of the seclusion.
The nurse is planning care for a client who is experiencing anxiety after a myocardial infarction. Which priority nursing intervention should be included in the plan of care?
- A. Answer questions with factual information.
- B. Provide detailed explanations of all procedures.
- C. Encourage family involvement during the acute phase.
- D. Administer an antianxiety medication to promote relaxation.
Correct Answer: A
Rationale: Accurate information reduces fear, strengthens the nurse-client relationship, and assists the client with dealing realistically with the situation. Providing detailed information may increase the client's anxiety. Information should be provided simply and clearly. Encouraging family involvement may or may not be helpful. Medication should not be used unless necessary.
A client having premature ventricular contractions states to the nurse, 'I'm so afraid that something bad will happen.' Which action by the nurse provides the most immediate help to the client?
- A. Telephoning the client's family
- B. Using a television to distract the client
- C. Having a staff member stay with the client
- D. Giving reassurance that nothing will happen to the client
Correct Answer: C
Rationale: When a client experiences fear, the nurse can provide a calm, safe environment by offering appropriate reassurance, using therapeutic touch, and having someone remain with the client as much as possible. Options 1 and 2 do not address the client's fear, and option 4 provides false reassurance.
During the admission assessment of a client with a history of alcohol abuse for diagnosis of ruptured esophageal varices, the client says, 'I deserve this. I brought it on myself.' Which response is most therapeutic for the nurse to make to the client?
- A. Would you like to talk to the chaplain?
- B. Is there some reason you feel you deserve this?
- C. Not all esophageal varices are caused by alcohol.
- D. That is something to think about when you leave the hospital.
Correct Answer: B
Rationale: Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic alcohol abuse. It is important to obtain an accurate history regarding the client's alcohol intake. If the client is ashamed or embarrassed, he or she may not respond accurately. Option 2 is open-ended and allows the client to discuss his or her feelings about drinking. Option 1 blocks the nurse-client communication process. Options 3 and 4 are somewhat judgmental.
The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client?
- A. Grief
- B. Socialization issues
- C. Issues related to sensory perception
- D. Trouble with coping with a disease process
Correct Answer: D
Rationale: A client with Graves' disease may become irritable, nervous, or depressed. The signs and symptoms in the question support option 4. The information in the question does not support the remaining options.