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A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.
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A nurse is providing discharge teaching to a client following a right mastectomy. Which of the following statements should indicate to the nurse that the client has a healthy body image?
- A. Do I have to go home with drains?
- B. The incision looks like it is healing.
- C. My sister will change the dressing every day.
- D. When will all this pain start to go away?
Correct Answer: B
Rationale: A statement acknowledging the healing process suggests the client is adjusting positively to body image changes.
During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to high Fowler's.
- B. Request NPO status for the client.
- C. Check the client's respiratory rate and lung sounds.
- D. Measure the client's temperature.
Correct Answer: C
Rationale: A rapid infusion of IV fluid can cause fluid overload, leading to respiratory distress. Checking respiratory status helps assess for complications.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. This is the appropriate action because the patient, being African-American, is at increased risk for hypertension. Providing information on lifestyle modifications such as a healthy diet, regular exercise, and stress management can help prevent the development of hypertension. This proactive approach aligns with preventative care and promotes the patient's overall well-being.
Choice A is incorrect because annual appointments may not address potential risk factors for hypertension. Choice C, scheduling a PSA test, is not relevant to the patient's current health assessment. Choice D, providing a weight loss plan, may be beneficial but not directly related to hypertension risk reduction in this scenario.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. In Erikson's psychosocial development theory, school-age children (around 6-12 years old) are in the stage of industry vs. inferiority. During this stage, children seek to develop a sense of competence and accomplishment by mastering new skills and tasks. This is crucial to consider in planning home care for a child recovering from an acute asthma attack as fostering a sense of industry can positively impact their self-esteem and motivation to manage their health.
Choice A: Autonomy vs. shame and doubt is more relevant to toddlers, not school-age children. Choice B: Initiative vs. guilt is about preschoolers. Choice D: Identity vs. role confusion is for adolescents. Choices E, F, G are not provided, but they would not be relevant to the developmental stage of school-age children.
A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?
- A. You have nothing to worry about.
- B. Others who have had this procedure have had great results.
- C. Tell me more about your concerns.
- D. Why are you feeling so anxious?
Correct Answer: C
Rationale: The correct response is C: "Tell me more about your concerns." This is the best response because it shows active listening and empathy towards the client's feelings. By encouraging the client to express their concerns, the nurse can address specific fears or worries, providing reassurance and support tailored to the individual's needs. This open-ended question allows the client to share their feelings, leading to better communication and trust between the nurse and client.
Other choices are incorrect because:
A: "You have nothing to worry about." is dismissive and does not acknowledge the client's feelings.
B: "Others who have had this procedure have had great results." may minimize the client's anxiety and not address their specific concerns.
D: "Why are you feeling so anxious?" is a closed-ended question that may put the client on the spot and not facilitate open communication.