Nokea
A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, 'I'm not sure about this. What if it doesn't work and I'm just as bad off as before?' Which concern for the client should the nurse identify at this time?
- A. Anxiety and depression
- B. Inability to handle the treatment regimen
- C. Lack of knowledge about the surgical procedure
- D. Fear about the potential risks and outcomes of surgery
Correct Answer: D
Rationale: This client has indicated the surgical procedure and its outcome as the object of fear. Anxiety is present when the client cannot identify the source of the uneasy feelings. Presently there are not indications that the client is depressed. A client's inability to handle a treatment regimen would be when the client is not making needed adaptations to deal with daily life. Lack of knowledge would be when there is a lack of appropriate information.
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The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. help the client bathe and change into fresh clothing before the examination begins
- B. preserve any evidence, including clothing, and take photographs of injuries as appropriate
- C. assure the client that surviving the assault is most important, and she did what was needed to stay alive
- D. take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
- E. tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Correct Answer: B,C,D
Rationale: Bathing before examination destroys evidence, making A incorrect. Preserving evidence (B), providing reassurance (C), and ensuring a private setting (D) are appropriate. Blaming the victim's clothing (E) is inappropriate and victim-shaming.
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
- A. Risk of tachycardia
- B. Probability of fatigue
- C. High incidence of hypoglycemia
- D. Possible exacerbation of depression
Correct Answer: D
Rationale: Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia rather than tachycardia. Fatigue is a possible side effect, but it is not the most important item. Hypoglycemia is a sign that is masked with beta blockers.
During the nursing assessment, the client states, 'My surgeon just told me that my cancer has spread, and I have less than 6 months to live.' Which nursing response would be the most therapeutic?
- A. I am sorry. Would you like to discuss this with me some more?'
- B. I am sorry. There are no easy answers in times like this, are there?'
- C. I hope you'll focus on the fact that your doctor says you have 6 months to live and that you'll think of how you'd like to live.'
- D. I know it seems desperate, but there have been a lot of breakthroughs. Something might come along in a month or so to change your status drastically.'
Correct Answer: A
Rationale: The client has received very distressing news and is most likely still experiencing shock and denial. In option 1, the nurse invites the client to ventilate feelings. Option 2 is social and expresses the nurse's feelings rather than the client's feelings. Option 3 is patronizing and stereotypical. Option 4 provides social communication and false hope.
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
- A. Do you want me to call your daughter?'
- B. Can you tell me a little about what has you so upset?'
- C. Try not to be so upset. Psychological stress is bad for your heart.'
- D. I understand how you feel. I'd cry, too, if I had a major heart attack.'
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.
The nurse provides care for a client who exhibits the signs and symptoms of acute confusion and delirium. Which strategy is appropriate for the nurse to implement?
- A. Keep the room organized and clean.
- B. Maintain a high environmental noise level.
- C. Keep lights in the room dimmed during the day.
- D. Use restraints as needed for client safety.
Correct Answer: A
Rationale: Keeping the room organized and clean minimizes sensory overload and confusion, promoting a calming environment for a client with delirium. High noise, dim lights, or restraints can worsen agitation and are not appropriate unless safety is imminently threatened.