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A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, 'I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.' The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?
- A. Bargaining
- B. Denial
- C. Depression
- D. Anger
Correct Answer: B
Rationale: The correct answer is B: Denial. The client's statement indicates denial as they are refusing to accept the reality of their condition and are hopeful that their kidneys are functioning again, despite the need for dialysis. This stage in Kübler-Ross's stages of grieving involves avoiding the truth to cope with the overwhelming emotions. Bargaining (A), Depression (C), and Anger (D) are not demonstrated in the client's statement. Bargaining involves seeking alternatives to the situation, Depression involves feelings of sadness and hopelessness, and Anger involves frustration and resentment.
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A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
- A. It delivers a specific concentration of oxygen constantly.
- B. It delivers the highest concentration of oxygen possible.
- C. It delivers the low concentration of oxygen you need.
- D. It allows you to remove it for a while when it gets uncomfortable.
Correct Answer: C
Rationale: The correct answer is C: It delivers the low concentration of oxygen you need. Nasal cannulas deliver a low flow rate of oxygen, typically between 1-6 liters per minute, providing a lower concentration of oxygen compared to other oxygen delivery devices. This is suitable for clients who require only a slight increase in their oxygen levels. Choice A is incorrect as nasal cannulas do not deliver a specific concentration of oxygen constantly. Choice B is incorrect as nasal cannulas do not deliver the highest concentration of oxygen possible. Choice D is incorrect because nasal cannulas should not be removed when uncomfortable as it disrupts the oxygen therapy.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress notes
Correct Answer: A
Rationale: The correct answer is A: Client concerns. The primary source of accurate data about the client should always be the client themselves. Clients are the most reliable sources of information regarding their own health, symptoms, and preferences. By directly asking the client about their concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but may not always be completely accurate. Medical history (C) and progress notes (D) are important sources of information but may not always reflect the client's current status or concerns. It is crucial to prioritize the client's perspective to ensure personalized and effective care.
A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching?
- A. The client achieves optimal personal growth.
- B. The nurse forms a personal identity.
- C. The client allows the nurse to satisfy his personal needs.
- D. The nurse's needs take priority over the client's needs.
Correct Answer: A
Rationale: The goal of a therapeutic relationship is to help the client achieve personal growth and well-being.
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
- A. Measure from the client's heel to the gluteal fold.
- B. Measure the length of the client's feet.
- C. Measure from the client's heel to the popliteal space.
- D. Measure the client's ankle circumference.
Correct Answer: C
Rationale: The correct answer is C: Measure from the client's heel to the popliteal space. This is the correct action because knee-high antiembolic stockings should cover the area from the heel to just below the knee at the popliteal space. This measurement ensures proper sizing and compression effectiveness.
A: Measuring from the heel to the gluteal fold is incorrect as it would result in stockings that are too long and may impede circulation.
B: Measuring the length of the client's feet is irrelevant for determining the correct size of knee-high stockings.
D: Measuring the client's ankle circumference alone is insufficient for determining the appropriate length of knee-high stockings.
In summary, choice C is correct as it ensures the stockings fit properly, while the other choices are incorrect due to inaccuracies or irrelevance in determining the appropriate size for knee-high antiembolic stockings.
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?
- A. Red mucous membranes
- B. Jugular vein distention
- C. Skin tenting
- D. BP 178/90 mm Hg
Correct Answer: C
Rationale: Skin tenting is a hallmark sign of dehydration due to decreased skin elasticity. Jugular vein distention and high BP indicate fluid overload.