Nokea
A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information should the nurse initially provide to the client?
- A. It is very likely that the client will need dialysis within 5 to 10 years.
- B. One kidney is adequate to meet the needs of the body, as long as it has normal function.
- C. There is absolutely no chance of the client needing dialysis because of the nature of the surgery.
- D. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.
Correct Answer: B
Rationale: Fears about having only one functioning kidney are common among clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs as long as it has normal function. This information supports that the remaining options are inaccurate.
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A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the client wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take?
- A. Make eye contact with the client and ask about the accident.
- B. Accompany the client into the restroom to obtain a urine sample.
- C. Ask the husband if the wife had been drinking alcohol.
- D. Escort the couple to an examining room to await the health care provider.
Correct Answer: D
Rationale: Escorting the couple to an examining room prioritizes a safe, private assessment of the client’s condition post-accident, especially given signs of possible abuse (missed appointments, anxiety). Direct questioning or accusations may escalate tension, and a urine sample is not the priority.
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.
The nurse provides care for four clients who require teaching about their medical conditions. The nurse assesses that which client is the most ready to learn?
- A. A client who woke up from a nap recently, just ate a snack, and is sitting up in bed.
- B. A client who was just informed of a cancer diagnosis by the health care provider.
- C. A client recovering from a stroke who has returned from physical therapy.
- D. A client who received pain medication 5 minutes ago for relief of discomfort.
Correct Answer: A
Rationale: A client who is rested, nourished, and alert (after a nap and snack, sitting up) is in an optimal state for learning. Recent diagnosis, fatigue from therapy, or recent pain medication may impair readiness to learn.
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, 'I'm scared to death that it'll come back.' Based on these statements, which concern should the nurse identify for this client at this time?
- A. Fear of dying
- B. Lack of understanding about the disease process
- C. Anxiety about the anticipation of recurrent severe pain
- D. Retention of urine from the obstruction of the urinary tract by calculi
Correct Answer: C
Rationale: The client stated, 'I'm scared to death that it'll come back.' The anticipation of the recurring pain produces anxiety and threatens the client's psychological integrity. There is no evidence that the client has a calculus in the right ureter. There is also no evidence that the client has lack of knowledge or urinary retention.
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.