Nokea
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.
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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.
The nurse provides care for an older adult client who is disoriented to person, place, and time. The client has an incontinence episode. Which statement by the nurse is most appropriate?
- A. Let's see about placing an indwelling catheter.
- B. Why didn't you call us for assistance?
- C. Here are some dry clothes for you to wear.
- D. Let's clean up and put on some dry clothes.
Correct Answer: D
Rationale: Offering to clean up and provide dry clothes is compassionate, maintains dignity, and addresses the immediate need without judgment. Catheters are invasive, blaming the client is inappropriate, and simply offering clothes does not address hygiene.
A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, 'I'm not sure I can take any more of this treatment.' Which therapeutic response should the nurse make to the client?
- A. Let's just put the tube down, so that you can get well.'
- B. If you don't have this tube put down, you will just continue to vomit.'
- C. You are feeling tired and frustrated with your recovery from surgery?'
- D. It is your right to refuse any treatment. I'll notify the primary health care provider.'
Correct Answer: C
Rationale: In option 3, the nurse uses empathy. Empathy, comprehending, and sharing a client's frame of reference are important components of the nurse-client relationship. This assists clients with expressing and exploring feelings, which can lead to problem-solving. The other options are examples of barriers to effective communication, including option 1, which is stereotyping; option 2, which is defensiveness; and option 4, which is showing disapproval.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, 'I know I need it, but I'm not sure this surgery is a great idea.' Which nursing response should best help the nurse assess the client's preoperative concerns?
- A. How does your family feel about the surgery?
- B. Has anyone taught you about the procedure yet?
- C. You sound extremely worried. Has anyone told you that the technology is really quite safe?
- D. You sound uncertain about the procedure. Can you tell me more about what has you concerned?
Correct Answer: D
Rationale: Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's concerns. Options 2 and 3 are closed-ended and are not exploratory.