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A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: The correct nursing intervention for the client in this scenario is to provide interactions to help the client learn to trust staff. This approach focuses on building trust and establishing a therapeutic alliance between the client and the healthcare team. Choice A is incorrect because simply convincing the client that the hospital staff is trying to help may not address the underlying issue of trust. Choice B is not the priority at this stage as the client is exhibiting symptoms of paranoia and discomfort. Choice D may further isolate the client and hinder the therapeutic relationship. Therefore, the most appropriate intervention is to engage in interactions that promote trust and a therapeutic connection between the client and the staff.
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At a senior citizens meeting, a healthcare professional talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
- A. ''I give myself insulin injections in my thighs.''
- B. ''Sometimes when I put my shoes on, I don't know where my toes are.''
- C. ''Here are my glucose readings that I noted on my calendar.''
- D. ''If I bathe more than once a week, my skin feels too dry.''
Correct Answer: B
Rationale: The correct answer is when the client states, ''Sometimes when I put my shoes on, I don't know where my toes are.'' This statement indicates peripheral neuropathy, which can lead to a lack of sensation in the lower extremities. When clients are unable to feel pressure or pain in their feet, they are at a high risk for skin impairment, such as cuts, wounds, or ulcers. Option A is not directly related to impaired skin integrity, as self-administering insulin in the thighs does not pose a direct risk to skin integrity. Option C shows good glucose monitoring, which is important but does not directly indicate impaired skin integrity. Option D suggests dry skin due to infrequent bathing, which is more related to general skin care and not as predictive of impaired skin integrity as the statement in Option B.
A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
- A. Administer anti-anxiety medications as prescribed by the healthcare provider
- B. Engage in a conversation with the client regarding methods to enhance rest and sleep
- C. Escort the client to a private room and stay with them
- D. Review the client's medical history to determine previous treatment for these issues
Correct Answer: C
Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
Which of the following is a nursing intervention for a client who is experiencing an acute panic attack?
- A. Encourage the client to sit down in a quiet environment
- B. Allow the client to direct the situation
- C. Try to focus the client on one aspect of care, such as regulating breathing patterns
- D. Speak in a commanding tone of voice to get the client's attention
Correct Answer: C
Rationale: When assisting a client with an acute panic attack, the primary goal is to help reduce their anxiety levels. Encouraging the client to focus on one controllable aspect, like regulating breathing patterns, can aid in calming them down. This intervention helps the client to regain control over their breathing, which can alleviate some of the symptoms associated with panic attacks. Options A and B are incorrect because allowing the client to direct the situation or sit down in a quiet environment may not be beneficial during an acute panic attack. Option D is inappropriate as speaking in a commanding tone can further escalate the client's anxiety rather than helping to calm them down.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
- A. Assist the client to walk to the bathroom and do not leave the client alone.
- B. Request that the UAP assist the client onto a bedpan.
- C. Ask if the client needs to have a bowel movement or void.
- D. Assess the client's bladder to determine if the client needs to urinate.
Correct Answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. Therefore, the nurse should assist the client to the bathroom to ensure safety. Using a bedpan is not necessary if the client can safely walk to the bathroom. Asking about bowel movements or voiding, as in option C, is irrelevant to the immediate safety concern of assisting the client to the bathroom. Assessing the client's bladder, as in option D, is unnecessary in this situation as there is no indication that the client cannot communicate his or her needs effectively. The priority here is to prevent falls and ensure the client's safety while assisting to the bathroom.
A 17-year-old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client's father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?
- A. Contact an interpreter to give the information again in the father's native language
- B. Continue to provide information about surgery to both the client and his parents
- C. Call social services to evaluate the parent's standard of care
- D. Contact the physician about postponing the surgery
Correct Answer: B
Rationale: Nurses may work with clients who have varying cultural beliefs. Because of this, nurses must remain aware of the cultural practices associated with certain ethnic groups. Asian Americans may avoid eye contact as a sign of respect; additionally, emotional responses may be avoided except for in private situations. If this family did not have a language barrier, the nurse should continue to provide appropriate information about the surgery and recognize the cultural differences that exist. Contacting an interpreter is not necessary as there was no mention of a language barrier. Calling social services to evaluate the parent's standard of care is premature and not within the nurse's immediate scope of practice. Contacting the physician about postponing the surgery is not warranted based on the information provided.