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A client recovering from a brain attack (stroke) has become irritable and angry regarding self-limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable?
- A. Ignore the behavior, knowing that the client is grieving.
- B. Allow longer and more frequent visitation by the spouse.
- C. Use supportive statements to correct the client's behavior.
- D. Stress that the nurses are experienced and know how the client feels.
Correct Answer: C
Rationale: Clients who have experienced a stroke have many and varied needs. It is also important to support and praise the client for accomplishments. The client may need her or his behavior pointed out so that correction can take place, and the client's behavior should not be ignored. Spouses of a stroke client are often grieving; therefore, more visitations may not be helpful. Additionally, short visits are often encouraged. Stating that the nurse knows how the client feels is inappropriate.
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A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and should base the discussion on which information?
- A. Rest is an essential component of bone healing.
- B. Setting limits on a client's behavior is a mandated nursing role.
- C. Not keeping up with his job will increase the client's stress level.
- D. Involvement in his job will keep the client from becoming bored.
Correct Answer: A
Rationale: Rest is an essential component of bone healing, particularly after a hip fracture repair with a prosthetic implant. Engaging in work-related activities, such as planning a phone meeting, may interfere with the necessary rest and recovery process. Options 2, 3, and 4 do not prioritize the physiological need for rest and healing, which is critical at this stage of recovery.
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
- A. Tell me what you think you did wrong.'
- B. Maybe we can keep your father in the hospital for a while longer to give you a rest.'
- C. You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care.'
- D. An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed.'
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
A client in the long-term care facility is confused and repeatedly asks the nurse for help finding the assigned room. Which response by the nurse is appropriate?
- A. Here is a map of the facility, including the room numbers.
- B. I think you can find your room if you just concentrate.
- C. Your room is on the first floor by the elevator doors.
- D. You didn't have any trouble finding your room yesterday.
Correct Answer: C
Rationale: Providing a clear, specific direction (room location by the elevator) helps orient the confused client without frustration. Maps are too complex, urging concentration is unhelpful, and referencing past ability may cause distress.
A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse should initially allow the client to continue this behavior because it has what therapeutic effect for the client?
- A. Relieves the client's anxiety
- B. Decreases the chance of infection
- C. Gives the client a feeling of self-control
- D. Increases the client's sense of self-esteem
Correct Answer: A
Rationale: The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Options 2 and 3 are also incorrect interpretations of the client's need to perform this behavior. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
- A. I'm so angry that this happened to me.
- B. I really don't want to live my life like this.
- C. I'm definitely not looking forward to going home.
- D. I don't know if I can make all these major adjustments to my life.
Correct Answer: B
Rationale: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.