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A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension?
- A. Suggesting the client watch television during the procedure as a distraction
- B. Talking to the client from the foot of the bed and assisting with the procedure
- C. Staying beside the client to give information and encouragement during the procedure
- D. Assuring the client that even though there are other clients needing care, the client's needs are most important
Correct Answer: C
Rationale: Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure.
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A client is demonstrating confusion as a result of bed rest and a prolonged length of hospital stay. The client receives a prescription for progressive ambulation as tolerated. Which is the best nursing intervention to use to implement the prescription?
- A. Ambulate to the client's bathroom three times a day.
- B. Ambulate in the room for short distances frequently.
- C. Ambulate in the hall progressively three times a day.
- D. Assist with range-of-motion exercises three times a day.
Correct Answer: C
Rationale: The cause of the client's confusion is bed rest and decreased sensory stimulation from a prolonged length of stay; therefore, the best intervention is to ambulate the client in the hall to increase sensory stimulation. Hopefully the stimulation can help decrease the confusion. Options 1 and 2 do not address the client's need for sensory stimulation. The nurse performs option 4 in preparation for ambulation while the client is on bed rest.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
A client who received an implanted port for intermittent chemotherapy says, 'I'm not sure if I can handle having a tube coming out of me. What will my friends think?' Which action should the nurse implement first?
- A. Show the client various central line catheters.
- B. Assure the client that his friends will understand.
- C. Explain that implanted ports are subcutaneous and not visible.
- D. Notify the primary health care provider of the client's concerns.
Correct Answer: C
Rationale: An implanted port is subcutaneous; it is not visible, and it has no external tubing. Tubing is used when an intravenous line is connected, and the port is accessed for therapy. The remaining options do not correct the client's confusion about the implanted port. Notifying the provider is not indicated. Inquiring about the client's friends is a reasonable response, but it can also provide false hope that the friends will be accepting. In addition, the nurse is likely to cause more anxiety and concern by providing information about the catheter's subcutaneous location. Showing various central line catheters is unlikely to be beneficial because the client will not be using them; in addition, this can heighten client anxiety and concerns.
A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, 'The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?' Which is the most appropriate therapeutic response the nurse should make to the client?
- A. Any invasive procedure brings risk with it. You need to report any shoulder pain immediately.'
- B. You seem to understand the preparation very well. Are you having any concerns about the procedure?'
- C. Trouble? There is never any trouble with this procedure. That's why the surgeon will use local anesthesia.'
- D. There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported immediately.'
Correct Answer: B
Rationale: Abdominal peritoneoscopy is performed to directly visualize the liver, gallbladder, spleen, and stomach after the insufflation of nitrous oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the abdomen. A microscope in the endoscope allows for the visualization of the organs and provides a way to collect a specimen for biopsy or remove small tumors. The appropriate response is the one that facilitates the expression of the client's feelings. Option 1 may increase the client's anxiety. In option 3, the nurse states that no problems are associated with this procedure; this is closed-ended and is incorrect. Although option 4 contains accurate information, the word immediately can increase the client's anxiety.
The nurse is caring for a client who has been diagnosed with terminal pancreatic cancer. The family is asking what to expect when the end draws near. Which response by the nurse is most appropriate?
- A. I will have the doctor talk to you about that.
- B. The hospice nurse is the best person to answer your questions. I can put in a consult for you.
- C. Don't worry about that right now. You don't know if there is another treatment option that will work.
- D. I can tell you what to look for when the time comes. In the meantime, what are your wishes and goals for care?
Correct Answer: D
Rationale: This response addresses the family's question while opening a discussion about care goals, which is supportive and appropriate.