Nokea
A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
You may also like to solve these questions
16. Which statement accurately describes the common use of feverfew?
- A. Frequently used for insomnia and anxiety
- B. Most commonly used for prevention of migraine headaches
- C. Frequently used to prevent and treat upper respiratory infections
- D. Often used by perimenopausal women to relieve menopausal symptoms
Correct Answer: B
Rationale: Feverfew is most commonly used for the prevention of migraine headaches, making option B the correct answer.
A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?
- A. Administer pain medication as ordered.
- B. Check the client's blood pressure.
- C. Place the client in a supine position.
- D. Increase the client's fluid intake.
Correct Answer: B
Rationale: The correct action is to check the client's blood pressure first. A sudden onset of pounding headache and blurred vision in a client with a spinal cord injury at T6 can indicate autonomic dysreflexia. Checking the blood pressure is crucial as autonomic dysreflexia can lead to severe hypertension, which can result in life-threatening complications such as stroke or seizure. Immediate assessment and intervention are necessary to prevent further harm. Administering pain medication without addressing the underlying cause can exacerbate hypertension. Placing the client in a supine position can worsen symptoms, and increasing fluid intake does not address the immediate issue at hand. Therefore, checking the blood pressure is the priority to identify and manage autonomic dysreflexia effectively.
Place the events below in the order they occur in the patient with obstructive sleep apnea (beginning with 1).
- A. Sleep just before going to work
- B. Narrowing of air passages with muscle relaxation during sleep
- C. Apnea lasting 10 to 90 seconds
- D. Brief arousal and airway opened
Correct Answer: C
Rationale: The correct order is E (narrowing), A (apnea), C (arousal). Muscle relaxation leads to airway narrowing, followed by apnea and then arousal.
Match the following data with the assessment technique used to obtain the information.
- A. Normal blood flow through arteries
- B. Abnormal blood flow in carotid artery
- C. Tympany of the abdomen
- D. Pitting edema
Correct Answer: D
Rationale: The correct match depends on the technique: Auscultation detects normal/abnormal blood flow, percussion reveals tympany, and palpation identifies pitting edema.
Priority Decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do?
- A. Teach the patient controlled breathing
- B. Explain the rationale for these activities
- C. Provide adequate and regular pain medication
- D. Use an incentive spirometer to motivate the patient
Correct Answer: C
Rationale: Pain management enables patients to perform respiratory exercises effectively, preventing complications.