Nokea
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?
- A. Ask a family member to stay with the client during the procedure.
- B. Give the client the call bell, and encourage its use if the client feels worse.
- C. Leave the client alone only to gather the required equipment and medications.
- D. Stay with the client, and ask another nurse to gather needed equipment and supplies.
Correct Answer: D
Rationale: The client with pulmonary edema is experiencing severe anxiety, which can exacerbate the condition and hinder treatment. Staying with the client provides emotional support and reassurance, addressing the psychosocial aspect of care, while delegating equipment gathering ensures efficient preparation for treatment. This holistic approach meets both the emotional and physical needs of the client. Option 1 may not be feasible or sufficient to address immediate anxiety. Option 2 does not provide active support, and option 3 leaves the client alone, which could increase anxiety.
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The nurse overhears the supervisor reprimand the charge nurse for not discussing feelings with a client. Shortly after, a client asks the charge nurse for an extra blanket. The charge nurse angrily responds, 'Get it yourself!' The nurse recognizes the charge nurse is displaying which defense mechanism?
- A. Compensation.
- B. Displacement.
- C. Conversion.
- D. Projection.
Correct Answer: B
Rationale: Displacement involves redirecting emotions from one target to another. The charge nurse, upset from the reprimand, displaces anger onto the client by responding harshly to a simple request, rather than addressing the supervisor.
A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
- A. Finding out your baby has a serious health problem must be painful.
- B. How does your husband feel about this problem?
- C. How is your baby doing now?
- D. What you need to do is to focus on the present.
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
- A. monitor the airway and be prepared to provide suction if needed
- B. continuously observe vital signs and cardiac function on the monitor
- C. provide support and safe positioning to the client's arms and legs during the seizure
- D. record the type, frequency, duration, and amount of movement induced by the seizure
Correct Answer: A
Rationale: Airway management is the priority during ECT due to the risk of aspiration or respiratory compromise during induced seizures.
The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which should the nurse assess to yield the best information about this area of functioning?
- A. Judgment
- B. Emotions
- C. Consciousness
- D. Eye movements
Correct Answer: B
Rationale: Feelings and emotions are part of the role of the limbic system. Eye movements are under the control of cranial nerves III, IV, and VI. The level of consciousness is controlled by the reticular activating system. Insight, judgment, and planning are part of the function of the frontal lobe.
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.