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A client who received an implanted port for intermittent chemotherapy says, 'I'm not sure if I can handle having a tube coming out of me. What will my friends think?' Which action should the nurse implement first?
- A. Show the client various central line catheters.
- B. Assure the client that his friends will understand.
- C. Explain that implanted ports are subcutaneous and not visible.
- D. Notify the primary health care provider of the client's concerns.
Correct Answer: C
Rationale: An implanted port is subcutaneous; it is not visible, and it has no external tubing. Tubing is used when an intravenous line is connected, and the port is accessed for therapy. The remaining options do not correct the client's confusion about the implanted port. Notifying the provider is not indicated. Inquiring about the client's friends is a reasonable response, but it can also provide false hope that the friends will be accepting. In addition, the nurse is likely to cause more anxiety and concern by providing information about the catheter's subcutaneous location. Showing various central line catheters is unlikely to be beneficial because the client will not be using them; in addition, this can heighten client anxiety and concerns.
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The nurse is caring for a client diagnosed with Hodgkin's disease who will be receiving radiation and chemotherapy. Which statement by the client indicates a positive coping mechanism to be used during these treatments?
- A. I won't leave the house bald.'
- B. Losing my hair won't bother me.'
- C. I will be one of the few who doesn't lose my hair.'
- D. I have selected a wig, even though I will miss my own hair.'
Correct Answer: D
Rationale: A combination of radiation and chemotherapy often causes alopecia. To make use of positive coping mechanisms, the client must identify personal feelings and positive interventions to deal with side effects. None of the remaining options are positive coping mechanisms.
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.
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.
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 precepting a new nurse in the psychiatric unit. The nurse is discussing interventions for schizophrenia. Which statement by the student nurse indicates an understanding of management of schizophrenia? Select all that apply.
- A. I should be warm and friendly to put the client at ease.
- B. I can reassure the client that he is in a safe environment.
- C. Puzzles or word games are good activities to engage in.
- D. I can help the client use art or writing to express his feelings.
- E. I won't tell the client when I'm leaving him so he won't get upset.
Correct Answer: B,C,D
Rationale: Reassurance of safety, engaging activities like puzzles, and expressive therapies are appropriate. Overly warm approaches or withholding departure information can increase anxiety or mistrust.