Nokea
A client is having a panic attack. Which nursing intervention has priority for this client?
- A. have the client recount a positive childhood memory
- B. provide the client with a glass of water
- C. tell the client to take deep breaths
- D. ask the client to identify the source of his anxiety
Correct Answer: C
Rationale: Deep breathing helps reduce hyperventilation and physiological symptoms during a panic attack, making it the priority intervention.
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Which method is used to verify the placement of a newly inserted central venous access device (CVAD)?
- A. Chest x-ray
- B. Flushing the line with heparin
- C. Withdrawing blood to ensure patency
- D. Chest fluoroscopy
Correct Answer: A
Rationale: The correct method to verify the placement of a newly inserted central venous access device (CVAD) is a chest x-ray. This is crucial to detect any potential complications such as pneumothorax, which can occur during subclavian vein catheter insertion. Symptoms of pneumothorax may include shortness of breath and anxiety. Flushing the line with heparin is not used for placement verification, but rather for maintaining patency after verification. Withdrawing blood to ensure patency is done after placement is confirmed, not for initial verification. Chest fluoroscopy may be used during the insertion process but is not typically employed for placement verification.
A young adult client diagnosed with a spinal cord injury tells the nurse, 'It's so depressing that I'll never get to have sex again.' Which is the realistic reply for the nurse to make to the client?
- A. It must feel horrible to know you can never have sex again.'
- B. It's still possible to have a sexual relationship, but it will be different.'
- C. You're young, so you'll adapt to this more easily than if you were older.'
- D. Because of body reflexes, sexual functioning will be no different than before.'
Correct Answer: B
Rationale: It is possible to have a sexual relationship after a spinal cord injury, but it is different from what the client will have experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may help the client adapt to changes in sexuality after a spinal cord injury.
Which intervention does the nurse include in the plan of care for a client from a different culture?
- A. Being respectful of the client's needs.
- B. Expecting non-adherent behavior.
- C. Monitoring for difficulty with dietary restrictions.
- D. Offering a firm handshake upon leaving the client.
Correct Answer: A
Rationale: Respecting the client's cultural needs promotes trust and effective care, ensuring culturally sensitive interventions. Expecting non-adherence is biased, monitoring dietary restrictions is too specific, and a handshake may not be culturally appropriate.
The client is in the withdrawal phase of adjusting to the change in body image. Which reaction cues the nurse to realize this when caring for a client who has lost an arm in a motor vehicle accident?
- A. The client is going through a grieving period.
- B. The client talks as if another person is affected.
- C. The client is willing to learn techniques to adapt.
- D. The client recognizes the reality and becomes anxious.
Correct Answer: D
Rationale: In this scenario, the client's recognition of the reality and subsequent anxiety cues the nurse that the client is in the withdrawal phase of adjusting to the change in body image. During this phase, the client may refuse to discuss the change and may use withdrawal as a coping mechanism. The grieving period typically occurs during the acknowledgement phase, where the client and family come to terms with the change in physical appearance. Initially, shock and depersonalization may lead the client to talk as if another person is affected by the change. Finally, in the rehabilitation stage, the client is ready to learn techniques to adapt to the change, such as through the use of prosthetics or modifying lifestyles and goals.
The nurse observes that a client is restless, tense, and reports feeling empty. The nurse notes the client has a history of threatening self-mutilation. Which nursing action is appropriate?
- A. Monitor weight and dietary intake.
- B. Administer chlordiazepoxide.
- C. Provide food in client's own containers.
- D. Take inventory of the client's room.
Correct Answer: D
Rationale: Taking inventory of the client’s room ensures safety by identifying and removing potential tools for self-harm, given the history of threatened self-mutilation. Other actions do not directly address the immediate risk.