Nokea
A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, 'The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?' Which is the most appropriate therapeutic response the nurse should make to the client?
- A. Any invasive procedure brings risk with it. You need to report any shoulder pain immediately.'
- B. You seem to understand the preparation very well. Are you having any concerns about the procedure?'
- C. Trouble? There is never any trouble with this procedure. That's why the surgeon will use local anesthesia.'
- D. There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported immediately.'
Correct Answer: B
Rationale: Abdominal peritoneoscopy is performed to directly visualize the liver, gallbladder, spleen, and stomach after the insufflation of nitrous oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the abdomen. A microscope in the endoscope allows for the visualization of the organs and provides a way to collect a specimen for biopsy or remove small tumors. The appropriate response is the one that facilitates the expression of the client's feelings. Option 1 may increase the client's anxiety. In option 3, the nurse states that no problems are associated with this procedure; this is closed-ended and is incorrect. Although option 4 contains accurate information, the word immediately can increase the client's anxiety.
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The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate?
- A. Prepare a schedule of activities and monitor the client's participation in the activities.
- B. Encourage the client to choose the client's own activities.
- C. Allow the client time to get acclimated to the milieu before scheduling activities.
- D. Allow the client to rest quietly to restore energy level.
Correct Answer: C
Rationale: Allowing time to acclimate helps the client adjust to the new environment, reducing stress and supporting engagement, especially given their cognitive and social challenges. Scheduling activities or encouraging choices may be premature, and rest alone does not address isolation.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?
- A. Poor self-care
- B. Body image insecurity
- C. Neck range of motion restrictions
- D. Uncontrolled pain related to the CVC
Correct Answer: B
Rationale: Psychosocial assessment includes client data related to psychological and social issues. The CVC can create socially awkward situations and impair the client's security in her body image. The client data presented do not support assessing the client for poor self-care. Although pain and neck range of motion are valid issues for this client, options 3 and 4 are physiological issues and do not relate to the concerns of the client.
The client who is dying states to the nurse, 'I hope I am worthy of heaven.' Which intervention should the nurse implement first after determining that this client is experiencing fear?
- A. Help the client express fears.
- B. Assess the nature of the client's fears.
- C. Help the client identify coping mechanisms that were successful in the past.
- D. Document verbal and nonverbal expressions of fear and other significant data.
Correct Answer: B
Rationale: Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.
A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension?
- A. Suggesting the client watch television during the procedure as a distraction
- B. Talking to the client from the foot of the bed and assisting with the procedure
- C. Staying beside the client to give information and encouragement during the procedure
- D. Assuring the client that even though there are other clients needing care, the client's needs are most important
Correct Answer: C
Rationale: Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure.