Nokea
A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client?
- A. Assign the client a new task to master.
- B. Turn on the television to a musical program.
- C. Make the client aware that the behavior is undesirable.
- D. Talk about the family pictures on display in the client's room.
Correct Answer: D
Rationale: Providing familiar objects will decrease anxiety. Decreasing environmental stimuli also aids in reducing agitation for the head-injured client. Option 1 does not simplify the environment because a new task may be frustrating. Option 2 increases stimuli. In option 3 the nurse uses negative reinforcement to help the client adjust.
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A client who is to be discharged to home with a temporary colostomy states to the nurse, 'I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?' Which therapeutic response should the nurse make to best deal with the client's concerns?
- A. This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery.'
- B. So you're saying that, although you've practiced changing your colostomy bag once, you don't feel comfortable on your own yet?'
- C. Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you'll have to fight it out with them.'
- D. Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable.'
Correct Answer: D
Rationale: The client is expressing feelings of fear and helplessness. Option 4 assists with meeting this client's needs. Option 1 provides information that the client already knows and then problem-solves by using a client-centered action, which would probably overwhelm the client. Option 2 is restating, but this response could cause the client to feel more helpless because the client's fears are reflected back to the client. Option 3 provides what is probably accurate information, but the words 'just to practice' can be interpreted by the client as belittling.
While in the dining area, an adult client at the retirement center yells, 'This turkey is dry and cold! I can't stand the food here!' Which is the best response by the nurse to the client's behavior?
- A. Now look what you've done! You're ruining this meal for the whole community. Aren't you ashamed of yourself?
- B. I think you had better return to your apartment now. I'll make arrangements for a new meal to be served to you there.
- C. Let me get you another serving that is more to your liking. Would you like to see the chef and select your own serving?
- D. One of the things that was agreed upon was that anyone who did not use appropriate behavior would be asked to leave the dining room. Please leave now.
Correct Answer: C
Rationale: Asking the client to accompany the nurse to the kitchen respects the client's need for control, removes the angry client from the dining room, and may offer the nurse an opportunity to assess what is happening with the client. Agency procedure should be followed regarding those who are allowed access to the facility kitchen. Option 1 is angry, aggressive, and nontherapeutic. Option 2 could provoke a regressive struggle between the nurse and the client and cause more anger in the client. In option 4, the nurse is authoritative, and it would not be appropriate to ask the client to leave. This action may set up an aggressive struggle between the nurse and the client.
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.
The client angrily tells the nurse that the primary health care provider (HCP) purposefully provided incorrect information. Which responses by the nurse to the client support therapeutic communication?
- A. I'm certain that the HCP would not lie to you.
- B. I'm not sure what you mean by that statement.
- C. Can you describe the information that you are referring to?
- D. Do you think it would be helpful to talk to your doctor about this?
- E. You can check the information on lots of websites on the Internet.
Correct Answer: B,C,D
Rationale: Options 2 and 3 attempt to clarify the information to which the client is referring. Option 4 attempts to explore whether the client is comfortable talking to the HCP about this issue and encourages direct confrontation. Options 1 and 5 hinder communication by disagreeing with the client and referring the client to the Internet instead of his HCP for clarification. This technique could make the client defensive and block further communication.
A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client's concerns?
- A. I can show you how to gently stroke the face and not cause pain.
- B. It is a normal finding in large babies and nothing to be concerned about.
- C. The bruising is caused by polycythemia, which usually leads to jaundice.
- D. Because the bruising is painful, it is advisable that you not touch the baby's face.
Correct Answer: A
Rationale: The mother of an LGA infant with facial bruising may be reluctant to interact with the infant because of concern about causing additional pain to the infant. Touching the infant gently with the fingertips should be encouraged. The bruising is temporary. Option 2 does not address the mother's verbalized concerns. The LGA infant may have polycythemia, which can contribute to bruising, but the bruising is not actually caused by the polycythemia. Option 4 advises the mother not to touch the baby's face because the bruising is painful, but touch is an important component of the attachment process.