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A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication should the nurse determine may be the best for the client?
- A. Use a picture or word board.
- B. Have the family interpret needs.
- C. Devise a system of hand signals.
- D. Use a pad of paper and a pencil.
Correct Answer: A
Rationale: The client with an endotracheal tube in place cannot speak, so the nurse devises an alternative communication system with the client. The use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. The family does not need to bear the burden of communicating the client's needs, and they may not understand the client either. The use of hand signals may not be a reliable method because it may not meet all needs, and it is subject to misinterpretation. A pad of paper and a pencil is an acceptable alternative, but it requires more client effort and time.
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The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
The nurse is planning care for a client with an intrauterine fetal demise. Which are appropriate goals for this client?
- A. The woman's grieving process will be limited to 6 months.
- B. The woman and her family will discuss plans for going home without the infant.
- C. The woman and her family will express their grief about the loss of their desired infant.
- D. The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.
- E. The woman and her family will contact their pastor or grief counselor for support after discharge.
Correct Answer: B,C,E
Rationale: It is important for the nurse to assess whether the client is undergoing the normal grieving process. Options 2, 3, and 5 are appropriate goals. Signs that are causes for concern and that are not part of the normal grieving process include thoughts of worthlessness and suicide and limiting the grieving process to a short amount of time.
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
- A. I'm so angry that this happened to me.
- B. I really don't want to live my life like this.
- C. I'm definitely not looking forward to going home.
- D. I don't know if I can make all these major adjustments to my life.
Correct Answer: B
Rationale: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.
The community health nurse reviews data on four families. Which client does the nurse evaluate first?
- A. A preschool-age client whose parent screams profanities at the client.
- B. An adolescent client who watches television all day while the parents operate a busy company.
- C. A school-age client who has poor hygiene, has small-fitting clothes, and has been caught stealing bicycles.
- D. An underweight adolescent client who is following a vegan diet.
Correct Answer: A
Rationale: A preschooler subjected to verbal abuse (screaming profanities) is at high risk for emotional and psychological harm, which can have long-term developmental impacts. This situation requires immediate evaluation to ensure the child's safety, taking priority over neglect, behavioral issues, or dietary concerns.