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A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of the following responses should the nurse make?
- A. Ask him to describe what he is feeling.
- B. Give the client some reading material as a distraction.
- C. Suggest that he take a walk around the unit.
- D. Refer him to the pastoral care team.
Correct Answer: A
Rationale: The correct response is A: Ask him to describe what he is feeling. This option encourages the client to express his emotions, which can help alleviate anxiety by providing an outlet for his concerns. By actively listening and acknowledging his feelings, the nurse can establish trust and rapport, leading to better emotional support. Choice B may provide a temporary distraction but does not address the underlying anxiety. Choice C may be physically beneficial but does not address the client's emotional state. Choice D may be helpful for spiritual support but does not directly address the client's anxiety.
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A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?
- A. "Of course people care. Your family comes to visit every day."
- B. "Tell me who you think doesn't care about you."
- C. "Why do you feel that way?"
- D. "I care about you, and I am concerned that you feel so sad."
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and acknowledges the client's feelings while also expressing concern. It validates the client's emotions and offers support without dismissing or invalidating their experience. Choice A is incorrect as it focuses on the family's visits, which may not address the client's underlying emotional distress. Choice B puts the client on the spot and may come off as confrontational. Choice C is open-ended but lacks the immediate reassurance and support the client needs.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Hand tremors
- B. Stuporous level of consciousness
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Hand tremors. During acute alcohol withdrawal, the central nervous system is hyperexcitable due to the sudden absence of alcohol. This can lead to symptoms such as hand tremors, anxiety, agitation, and even seizures. Stuporous level of consciousness (choice B) is not expected in alcohol withdrawal, as clients typically exhibit hyperactivity. Bradycardia (choice C) and hypotension (choice D) are unlikely findings, as alcohol withdrawal commonly causes increased heart rate and blood pressure due to sympathetic nervous system activation.
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility. The client asks the nurse why he has to go "to that place." Which of the following responses should the nurse make?
- A. "Your doctor feels that this is the best place for you right now."
- B. "Why don't you ask your doctor about that when she comes in to see you?"
- C. "Did your doctor or anyone else talk to you about going to the nursing home?"
- D. "Your family can't take care of you at home, so you will need to go there."
Correct Answer: C
Rationale: Encouraging discussion allows the client to express concerns and ensures they are informed about their care plan.
A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitamin B deficiency?
- A. A client who takes gabapentin as part of treatment for a seizure disorder.
- B. A client who has asthma.
- C. A client who has chronic alcohol use disorder.
- D. A client who takes heparin to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: A client who has chronic alcohol use disorder. Chronic alcohol use can lead to malabsorption of essential vitamins, including vitamin B. Alcohol interferes with the absorption and utilization of vitamin B, leading to a deficiency. This can result in various neurological and hematological complications. Clients with chronic alcohol use disorder are at high risk for vitamin B deficiency and should be closely monitored.
Incorrect Choices:
A: Gabapentin is not directly related to vitamin B deficiency.
B: Asthma does not directly increase the risk of vitamin B deficiency.
D: Heparin does not impact vitamin B levels significantly.